9366 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


PELVIC  NEOPLASMS 


PELVIC   NEOPLASMS 


BY 

FRANK  WORTHINGTON, LYNCH,  A.B.,  M.D. 

PROFESSOR  OF   QYNECOLOGY  AND   OBSTETRICS,    UNIVERSITY  OF  CALIFORNIA; 
DIRECTOR  OF   WOMAN'S   CLINIC,    UNIVERSITY  OF  CALIFORNIA   HOSPITAL 

AND 

ALICE  F.  MAXWELL,  B.S.,  M.D. 

INSTRUCTOR  IN   GYNECOLOQY  AND   OBSTETRICS,    UNIVERSITY   OF   CALIFORNIA  ; 

ATTENDING     GYNECOLOGIST    AND     OBSTETRICIAN, 

UNIVERSITY   OF   CALIFORNIA 


D.   APPLETON   AND    COMPANY 

NEW  YORK  LONDON 

1922 


COPYRIGHT,    IQ22,    BY 

D.  APPLETON  AND  COMPANY 


PRINTED    IN   THE    UNITED    STATES   Or    AMERICA 


Biomedieal 
Libraij 

WP 


PREFACE 

THE  object  of  this  monograph  is  to  present  in  complete  form  the  sub- 
ject of  pelvic  neoplasms. 

The  study  has  considered  the  various  growths  from  the  historical, 
histological  9. nd  clinical  aspects.  Especial  emphasis  has  been  laid  upon 
the  early  diagnosis  of  the  malignant  growths  and  upon  the  value  of 
the  various  therapeutic  methods,  and  particularly  upon  the  newer 
agents,  namely  radium  and  X-ray. 

The  literature  has  been  completely  reviewed  to  date  to  standardize 
our  knowledge  of  the  results  of  radiation  of  pelvic  neoplasms.  Broad- 
minded  comparisons  have  been  made  between  the  advantages  of  ray- 
ing and  surgery  in  treatment. 

Original  illustrations  have  been  made  of  all  interesting  or  unusual 
specimens  at  our  disposal  and  a  large  number  of  drawings  have  been 
copied  from  the  literature.  The  illustrations  were  prepared  by  Ralph 
Sweet. 

Dr.  Margaret  Schulze  contributed  valuable  assistance  in  helping 
review  the  literature. 

FRANK  WORTHIXGTOX  LYXCH 

and 
ALICE  F.  MAXWELL 


593GC2 

A  *- 


CONTENTS 

CHAPTER  PAGE 

1.    BENIGN  TUMORS  OF  OUTLET     . i 

Fibroma  of  the  vulva,  i — Classification,  i — Etiology,  2 — Appearance  and 
size,  3 — Degenerations,  9 — Symptoms,  10 — Diagnosis,  10 — Treatment,  n 
— Lipoma  of  the  vulva,  n — Diagnosis,  13 — Treatment,  13 — Sweat  gland 
tumors  of  the  vulva,  13 — Classification,  13 — Etiology,  14 — Histology,  15 — 
Size,  appearance  and  location,  15 — Symptoms,  16— Question  of  malig- 
nancy, 16 — Diagnosis,  16 — Treatment,  lo-5— Cysts  of  the  hymen,  16 — Micro- 
scopic appearance,  17 —  Histology,  17 — Etiology,  17  —  Symptoms,  17  — 
Treatment,  17 — Other  benign  tumors  of  the  vulva,  17. 

II.     MALIGNANT  TUMORS  OF  THE  OUTLET 20 

Carcinoma  of  the  vulva,  20 — Frequency,  20 — Age,  21 — Etiology,  21 — Ap- 
pearance and  structure  of  growth,  22  —  Classification,  23  —  Method  of 
extension,  24 — Symptoms,  24 — Diagnosis,  24 — Prognosis,  24 — -Treatment, 
24 — Results,  28 — Carcinoma  of  the  clitoris,  28 — Type  of  growth,  29 — 
Frequency,  29 — Etiology,  29 — Age,  30 — Gross  appearance  and  form,  30 — 
Histology,  32 — Symptoms,  32 — Treatment,  32 — Carcinoma  of  Bartholin 
glands,  32 — Classification,  33 — Etiology,  33 — Age,  34 — Gross  appearance, 
34 — Symptoms,  35 — Diagnosis,  35 — Prognosis,  35 — Treatment,  35 — Sar- 
coma of  the  vulva,  36— Classification,  36 — Frequency,  36 — Etiology,  37 — 
Age,  37 — Location  and  appearance  of  growth,  38 — Metastasis,  40 — Clinical 
picture,  40 — Symptoms,  40 — Diagnosis,  40 — Treatment,  40 — Prognosis,  40. 

III.  BENIGN  TUMORS  OF  VAGINA 42 

Cysts  of  vagina,  42 — Frequency,  43 — Classification,  43 — Etiology,  43 — Age, 
43 — Point  of  origin,  44 — Location  and  appearance,  44 — Histology,  44 — 
Types  of  cysts,  45 — Cysts  arising  from  vaginal  glands,  46 — Cysts  of 
Gartner's  ducts,  47 — Cysts  arising  from  Miiller's  ducts,  47 — Cysts  devel- 
oping from  the  ureter,  48 — Cysts  from  the  urethral  glands,  49 — Gas  cysts, 
49 — Echinococcus  cysts,  50 — Symptoms,  50 — Diagnosis,  50 — Differential 
diagnosis,  50 — Treatment,  50 — Fibromyoma  of  the  vagina,  51 — Etiology,  51 
— Age,  51 — Site  of  origin,  51 — Classification,  51 — Location,  51 — Form,  size 
and  appearance,  51 — Histology,  52 — Complications,  52 — Occurrence  with 
pregnancy,  52 — Symptoms,  52 — Diagnosis,  52 — Treatment,  52 — Prognosis, 
53- 

IV.  MALIGNANT  TUMORS  OF  VAGINA    .       .       .       .       . 54 

Carcinoma  of  the  vagina,  54 — Etiology,  55 — Classification,  55 — Location  of 
growth,  55 — Primary  growths,  appearance  and  form,  56 — Histology,  56 
— Method  of  growth,  56 — Complication  with  pregnancy,  57 — Symptoms, 
57 — Diagnosis,  57 — Prognosis,  57 — Sarcoma  of  the  vagina,  57 — Classifica- 
tion, 58 — Sarcoma  in  infancy,  58 — Etiology,  59 — Age,  59 — Point  of  origin, 
59 — Location,  59 — Appearance  and  form,  60 — Method  of  growth,  61 — 
Histologic  picture,  61 — Symptoms,  62 — Duration  of  the  disease,  62 — 
Diagnosis,  62 — Prognosis,  62 — Therapy,  62 — Sarcoma  of  the  adult,  63 — 
Classification,  63 — Etiology,  63 — Age,  63 — Appearance  and  form,  64 — 
Location,  65 — Histology,  65 — Method  of  growth,  66 — Symptoms,  66 — 
Diagnosis,  66 — Prognosis,  66 — Treatment,  67. 


viii  CONTENTS 


CHAPTER 


PAGE 


V.    BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 68 

Fibromyoma  of  the  uterus,  68— Definition,  68— Frequency,  68— Age,  70— 
Etiology,  70 — Histogenesis,  70 — Growth '  of  uterine  fibroids,  71 — Classi- 
fication, 72 — Submucous  fibroids,  73 — Intramural  fibroids,  74 — Subserous 
fibroids,  75— Cervical  fibroids,  76— Structure  of  uterine  fibromyoma,  79— 
Histology,  79 — Blood  supply,  80 — Lymph  supply  of  fibroids,  80 — Degen- 
eration of  fibroids,  80 — Frequency,  81  —  Benign  degenerations,  81 — 
Atrophy,  82 — Hyaline  degeneration,  82 — Calcareous  degeneration,  83 — 
Edema  and  cystic  degeneration,  84  —  Infection  and  suppuration,  86  — 
Necrosis  of  fibroids,  88— Red  degeneration,  89— Fatty  degeneration,  90— 
Malignant  degeneration,  90 — Sarcoma,  91 — Gross  appearance,  92 — Rela- 
tion of  uterine  fibroids  to  carcinoma,  93 — The  effect  of  uterine  fibroids  on 
neighboring  and  distant  organs,  95 — On  tubes  and  ovaries,  97 — On  the 
pelvic  organs,  98— Effect  on  distant  organs ;  cardiovascular  changes,  09 
— Kidney  changes,  101 — Nervous  symptoms,  101 — Symptoms,  102 — Hem- 
orrhage, 102 — Leukorrhea,  103 — Pain,  103 — Dysmenorrhea,  104 — Pressure 
symptoms,  104 — Bladder  symptoms,  104 — Diagnosis,  105 — Diagnosis  of 
small  fibroids,  105 — Diagnosis  of  large  uterine  fibroids,  106 — Inspection, 
106 — Palpation,  107 — Percussion,  107 — Vaginal  examination,  107 — Differ- 
ential diagnosis,  107 — Prognosis,  without  treatment,  no. 

VI.     FIBROIDS i12 

Treatment,  112 — Expectant  treatment,  112 — Systemic  medication,  113 — Dis- 
carded methods,  113  —  Nonradical  operative  treatment,  114  —  Palliative 
treatment,  115 — Treatment  of  fibroids  by  radiotherapy,  115 — Roentgen- 
ray  treatment  of  fibroids,  115 — Method  of  action,  116 — Indication  for 
X-ray  treatment,  116 — Centra-indications,  117 — Result  of  X-ray  treat- 
ment, 117 — Radium  treatment  of  fibroids,  120 — Indications,  120 — Contra- 
indications, 120 — Method  of  action,  121 — Technic,  121 — Dosage,  121 — 
Results,  122 — Radical  treatment,  123 — Positive  indications  for  operation, 
123 — Contra-indications  to  operation,  124 — Myomectomy,  126 — Abdominal 
myomectomy,  126 — Technic  in  subperitoneal  pedunculated  fibroids,  128 — 
Technic  in  subperitoneal  sessile  and  interstitial  fibroids,  130 — Technic  in 
intraligamentous  fibroids,  132 — Vaginal  myomectomy,  132 — Technic  in 
pedunculated  submucous  fibroids,  133 — Technic  in  nonpedunculated  sub- 
mucous  fibroids,  134 — Technic  in  interstitial  fibroids,  135 — Technic  in 
subperitoneal  fibroids,  135 — Technic  in  cervical  fibroids,  135 — Abdominal 
hysterectomy,  136 — Historical,  136 — General  remarks,  137 — Technic  for 
supravaginal  hysterectomy  in  uncomplicated  cases,  137  —  Preliminary 
preparation,  138 — Opening  the  abdomen,  138 — Delivery  of  the  tumor,  139 
— Technic  for  supravaginal  hysterectomy  with  removal  of  adnexa,  140 
— Separation  of  the  bladder  and  ligation  of  the  uterine  vessels,  140 — 
Incision  of  the  cervix  and  closure  of  the  stump,  141 — Covering  the 
abraded  areas,  141 — Closure  of  the  abdominal  incision,  142 — Technic  for 
supravaginal  hysterectomy  when  the  adnexa  are  normal,  142 — Panhys- 
terectotny  in  uncomplicated  cases,  142 — Atypical  operation  in  complicated 
cases,  145 — Kelly's  left  to  right  or  right  to  left  supravaginal  hysterectomy, 
148 — Pryor's  method,  149 — Kelly's  bisection  method,  152 — Technic  in 
fibroids  developing  from  the  posterior  cervical  corporeal  junction,  152 — 
Relation  between  fibroids  and  pregnancy,  155 — Sterility,  155 — The  effect 
of  pregnancy  on  the  tumor,  156 — Abortion,  158 — Fetal  position,  158 — 
Labor,  158 — Puerperium,  160— Treatment,  160. 

VII.    ADENOMYOMA  OF  THE  UTERUS  AND  OTHER  PELVIC  STRUCTURES     .       .       .       .163 
Frequency,   163 — Etiology,   163 — Adenomyoma  of  the  uterus,    165 — Adeno- 
myoma  in  a  uterus  of  relatively  normal  contour,  165— Subperitoneal  and 
intraligamentous  adenomyoma,   167 — Submucous  adenomyoma,   168 — Cer- 
vical   adenomyoma,    168 — Degenerations   of   uterine   adenomyoma,    168 — 


CONTENTS  ix 

CHAPTER  PAGE 

Condition  of  the  tubes  and  ovaries  in  adenomyoma,  169 — Symptoms  of 
uterine  adenomyoma,  169 — Physical  findings,  169 — Diagnosis,  170 — Prog- 
nosis, 171 — Treatment,  172 — Other  forms  of  adenomyoma,  172 — Adeno- 
myomata  of  the  rectovaginal  septum,  172 — Symptoms,  173 — Treatment, 
173- 

VIII.    CARCINOMA  OF  THE  UTERUS 176 

Frequency,  176 — Etiology,  177 — Age,  183 — 'Classification  of  uterine  cancer, 
185 — According  to  topography,  185 — According  to  histology,  186 — Accord- 
ing to  morphology,  186 — Squamous  cell  carcinoma  of  the  uterus,  187 — 
Squamous  cell  carcinoma  of  the  portio  vaginalis,  188 — Squamous  cell 
carcinoma  of  the  cervical  canal,  191 — Squamous  cell  carcinoma  of  the 
body  of  the  uterus,  192 — Adenocarcinoma  of  the  uterus,  193 — Adeno- 
carcinoma  of  the  cervix,  193 — Adenocarcinoma  of  the  body  of  the  uterus, 
196 — Carcinoma  of  the  cervix,  196 — Method  of  extension  of  cervical 
cancer,  196 — The  bladder,  198— The  rectum,  199 — The  lymph  nodes,  199 
— General  metastases,  203 — Symptoms  of  carcinoma  of  the  cervix,  205 — 
Leukorrhea,  206 — Hemorrhage,  206 — Clinical  course,  207 — Diagnosis,  208 
— Differential  diagnosis,  211 — Congenital  ectropion,  211 — Eversion  of  the 
cervix,  211 — Erosion,  211 — Ulceration  of  the  cervix,  nonmalignant,  asso- 
ciated with  prolapse,  211 — Hypertrophy  of  the  cervix,  21 1 — Lacerations 
of  the  cervix,  212 — Cervical  polypi,  212 — Submucous  fibroids,  212 — Tuber- 
culosis of  the  cervix,  212 — Syphilis  of  the  cervix,  212 — Condyloma  of  the 
cervix,  212 — Diphtheritic  patches,  213 — Sarcoma  of  the  cervix,  213 — 
Retained  portions  of  the  placenta,  213 — Endothelioma  of  the  cervix,  213 
— Prognosis,  213. 

IX.     TREATMENT  OF  CANCER  OF  THE  CERVIX 216 

Historical  Sketch,  216 — The  question  of  removing  pelvic  lymph  glands,  219 
—Operations  for  cervical  cancer,  221 — Selection  of  cases  for  operation, 
222 — Complications,  224 — Operability,  225— Choice  of  operation,  226 — 
Radical  abdominal  operations,  226 — The  Wertheim  operation,  227 — Dis- 
infection of  the  vagina,  227 — Abdominal  incision,  228 — Separate  steps  of 
the  operation,  228 — Ligation  of  the  uterine  artery,  229 — Exposure  of  the 
ureter  to  the  bladder,  230 — Venous  hemostasis,  231 — Incision  of  posterior 
peritoneum  and  separation  of  the  rectum,  232 — Extirpation  of  the  para- 
metrium,  232 — Extirpation  of  the  glands,  234 — Closing  the  peritoneum, 
234 — Drainage,  234 — Closing  without  drainage,  235 — After  treatment,  236 
— Complications,  236 — Complications  during  operation,  237 — Mackenrodt's 
operation,  238 — Complications,  241 — Bumm's  operation,  241 — The  para- 
vaginal  operation,  242 — Other  operations  for  cancer  of  the  cervix,  245 — 
The  cautery  method,  245 — Werder's  cautery  hysterectomy,  246 — Vaginal 
hysterectomy,  247 — High  cervical  amputation,  247 — Palliative  treatment 
of  cancer  of  the  uterine  cervix,  248 — General  methods,  249 — Acetone 
treatment,  249 — Cauterization,  250 — The  Percy  method  of  cauterization, 
250 — Method  of  calculating  results,  252 — Results  of  radical  operation  for 
carcinoma  of  uterine  cervix,  255 — Results  of  the  radical  vaginal  opera- 
tion, 260 — Results  of  less  extensive  methods,  260 — Vaginal  hysterectomy, 
261 — Treatment  of  recurrences  following  operation,  261 — Radiotherapy, 
262 — Radium,  263 — Thorium,  263 — Radium  rays  and  emanations,  263 — 
Alpha  rays,  264  —  Beta  rays,  264  —  Gamma  rays,  264  —  The  action  of 
radium,  264— Microscopic  appearance  of  tissues  subjected  to  radium,  266 
— Technic,  267 — Cross-fire,  270 — Complications,  272— Results  of  radium 
treatment,  272 — Treatment  of  operable  cervical  carcinoma  by  radium,  274 
— Treatment  of  border-line  carcinoma  by  radium,  274 — Treatment  of 
inoperable  carcinoma,  275 — Treatment  of  recurrences  following  opera- 
tion, 276 — The  question  of  operating  cases  which  appear  to  have  been 
made  operable  by  radium  treatment,  277 — Radium  treatment  preliminary 
to  operation,  278. 


x  CONTENTS 

CHAPTER  PAGE 

X.    CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY 279 

Carcinoma  of  the  uterine  body,  279 — Classification,  279 — Frequency,  279 — 
Etiology,  280 — Age,  280 — Appearance  and  form,  281 — Method  of  growth, 
282 — Complications,  283 — Multiple  cancers,  284 — Pyometra,  284 — Symp- 
toms, 284 — Diagnosis,  284 — Treatment,  285 — Radium,  288— Sarcoma  of- 
the  uterus,  288 — Frequency,  288 — Etiology,  289 — Age,  290 — Location  of 
the  tumor,  290 — Classification,  290 — Sarcoma  of  the  cervix,  293 — Special 
forms  and  mixed  types,  295 — Method  of  extension,  296 — Complications, 
296 — Symptoms,  297 — Sarcoma  of  the  uterine  wall,  297 — Sarcoma  of  the 
endometrium,  298— Sarcoma  of  the  cervix,  298 — Diagnosis,  298 — Prog- 
nosis, 298 — Treatment,  299. 

XI.    CHORIO-EPITHELIOMA 300 

Historical,  300 — Marchand's  theory,  301 — Attempts  at  classification  based 
on  histologic  picture,  302 — Frequency,  305 — Etiology,  306 — Age,  307 — 
Location  of  growth,  307— Period  of  latency  following  pregnancy,  310 — 
Metastases,  311 — Ovarian  changes,  associated  with  chorioma,  313 — Diag- 
nosis, 316— Prognosis,  318 — Treatment,  321 — Radium,  322. 

XII.     TUMORS  OF  THE  OVARY 323 

Classification,  323 — Frequency,  324 — Nonproliferating  cysts,  324— Follicle 
cysts,  325 — Corpus  luteum  cysts,  326 — Blood  cysts  of  the  ovary,  327 — 
Retention  cysts  not  derived  from  the  follicle,  327 — Tubo-ovarian  cysts, 
327 — Symptoms  of  nonprolif crating  cysts,  328 — Diagnosis,  328 — Treat- 
ment, 329 — New  formations,  331 — Parenchymatogenous  tumors,  331 — 
Epithelial  tumors,  331 — Cystadenomata,  331 — Pseudomucinous  cystaden- 
oma,  333 — Solid  adenomata,  336 — Cystadenoma  serosum,  336 — Racemose 
ovarian  cysts,  339 — Myxomatous  degeneration  of  surface  papillae,  339 — 
Other  adenomata,  340 — Ovarian  carcinoma,  340 — Etiology,  340 — Age,  341— 
Classification,  341 — Solid  ovarian  carcinoma,  342 — Cystic  carcinoma,  345 — 
Adenocarcinoma  pseudomucinosum,  347 — Folliculoma  malignum,  347 
— Primary  squamous  cell  epithelioma,  348 — Atypical  forms,  348 — The 
clear  cell  cancer,  348  —  Carcinoma  resembling  lymphosarcoma,  349  — 
Krukenberg  tumor,  349 — Metastatic  carcinoma,  350 — Clinical  features  of 
ovarian  cancer,  352 — Stages  of  growth,  352  —  Involvement  of  lymph 
glands,  353— Involvement  of  neighboring  organs,  353 — Symptoms,  354 — 
Complications,  355  —  Diagnosis,  355  —  Treatment,  355  —  Prognosis,  356 — 
Embryoma,  356-^-Etiology,  357 — Cystic  dermoids,  358 — Frequency,  358 — 
Age,  358 — Appearance  and  form,  358 — Structure,  359 — Atypical  forms 
of  dermoids,  361— Multiple  dermoids,  362 — Malignant  degeneration  of 
dermoids,  362  —  Teratoma,  365  — •  Struma  ovarii,  367  —  Stromatogenous 
tumors,  369 — Fibroma  and  myoma,  369 — Symptoms,  370— Diagriosis,  371 — 
Prognosis,  371 — Treatment,  371 — Osteoma  and  chondroma,  371 — Myx- 
oma,  371 — Angioma,  371 — Sarcoma  of  the  ovary,  372 — Myosarcoma,  373 
— Myxosarcoma,  373 — Melanosarcoma,  373 — Perithelioma,  angiosarcoma, 
374 — Metastatic  ovarian  sarcoma,  374 — Endothelioma  ovarii,  375 — Adeno- 
myoma  of  the  ovary,  376 — Mesonephric  tumors  of  the  ovary,  377 — 
Malignant  tumors  of  the  corpus  luteum,  377 — The  ovotestis  tumors,  377 
— General  symptoms  of  ovarian  tumors,  378 — Complications  of  ovarian 
tumors,  379. 

XIII.     TUMORS  OF  THE  BROAD  LIGAMENT,  THE  ROUND  LIGAMENT  AND  THE  FALLOPIAN 

TUBES * 383 

Tumors  of  the  broad  ligament,  383 — Tumors  of  the  round  ligament,  383 — 
Types  of  tumor  found,  384  —  Etiology,  384  —  Age,  385  —  Location  of 
growth,  385— Size  of  tumor,  385 — Microscopic  picture,  386 — Symptoms 
and  clinical  course,  386 — Diagnosis,  387 — Treatment,  387 — Prognosis,  387 
— Para-ovarian  tumors,  388 — Para-ovarian  cysts,  388 — Para-ovarian  tu- 


CONTENTS  xi 

CHAPTLR  PAGE 

mors  other  than  cysts,  390 — Cysts  of  the  hydatid  of  Morgagni,  390 — 
Cysts  from  accessory  fallopian  tubes  or  ostia,  390 — Solid  tumors  of  the 
broad  ligament,  391 — Fibromyoma,  391 — Age,  391 — Appearance  and  form, 
391 — Growth,  392  —  Degenerations,  392  —  Adenomyoma,  392 — Symptoms, 
392 — Lipoma,  393 — Sarcoma,  393 — Dermoids,  394 — Treatment  of  solid 
tumors  of  the  broad  ligament,  394 — Tumors  of  the  fallopian  tubes,  394 
— Benign  tumors  of  the  tubal  epithelium,  395 — Carcinoma  of  the  tube, 
396 — Papillary  carcinoma  or  malignant  papilloma,  398 — Adenocarcinoma, 
398  —  Diagnosis,  399 — Secondary  carcinoma  of  the  tube,  400 — Benign 
tumors  of  mesoblastic  origin,  400 — Malignant  tumors  of  mesoblastic 
origin,  401 — Embryonal  tumors,  401. 

XIV.     MAMMOTH  OVARIAN  TUMORS 403 

Historical,  403 — Complications,  405 — Type   of   fluid,  406 — Symptomatology, 
406 — Age,  407 — Prognosis,  407 — Resume  of  cases,  409. 


ILLUSTRATIONS 

FIGURE  PAGE 

1.  Fibroma  of  the  labium  majus  resembling  scrotum 3 

2.  Fibroma  of  labium  majus  with  well-developed  pedicle 4 

3.  Fibroid   of    labium   with   sarcomatous    degeneration 5 

4.  Pedunculated   multiple   fibroma 6 

5.  Mammoth  fibroma 7 

6.  Edematous  fibroma 9 

7.  Lipoma  of  left  labium   simulating   a  hernia  .                               12 

8.  Sweat  gland  tumor  of  vulva 14 

9.  Sweat  gland  tumor  of  vulva 15 

10.  Syphiloma   of   vulva   resembling   carcinoma 23 

11.  Carcinoma  of  right  labium  minora  in  woman  of  70 25 

12*  Area  of  removal  for  carcinoma  of  vulva 26 

13.  Carcinoma  clitoris  with  area  of  implantation  by  contact  on  the  left  labium  majus  31 

14.  Carcinoma  Bartholin  gland 34 

15.  Sarcoma  clitoris.        . 39 

16.  Incomplete  denudation  in  perineorrhaphy  from  which  cyst  may  arise.        .        .  43 

17.  Vaginal    inclusion    cyst 44 

18.  Cyst  in  Vagina 48 

19.  Vaginal  cyst  arising  from  imperfect  union  of  Miiller's  duct 49 

20.  Vaginal  cyst  representing  imperforate  and  rudimentary  vagina  of  right  side       .  49 

21.  Sarcoma  botryoids  in  child 60 

22.  Vaginal    sarcoma 64 

23.  Pedunculated  and  sessile  fibroid 69 

24.  Pedunculated  submucous  fibroid  with  partial  inversion  of  uterus 71 

25.  Soft  symmetrical  fibroid  simulating  six  months'  pregnancy 75 

26.  Cervical  fibroid 77 

27.  Cervical  fibroid ' 78 

28.  Large  subperitoneal  fibroid  with  marked  cystic  degeneration    .       .  85 

29.  Soft  fibroid  with  cystic  degeneration 86 

30.  Multiple  fibroids 87 

31.  Multiple  fibroids  with  sarcomatous  degeneration  in  the  lowest  tumor  ...  92 

32.  Multiple  fibroids  with  adenocarcinoma  of  fundus 93 

33.  Adnexal  complications  with  fibroids 97 

34.  Cystic  fibroids  suggesting  four  months'   pregnancy 108 

35.  Lateral  view  of  Figure  34 109 

36.  Adenocarcinoma    of    fundus   with   fibroids 118 

37.  Abdominal  myomectomy.     Fixing  the  tumor 127 

38.  Abdominal    myomectomy.      Shelling   out    the    tumor 129 

39.  Abdominal    myomectomy.      Closing    the    cavity    in    layers    to    secure    perfect 

approximation 130 

40.  Abdominal    myomectomy .131 

41.  Vaginal  myomectomy 134 

42.  Hysterectomy  conserving  the  tubes   and  ovaries   ........  143 

43.  Supravaginal  hysterectomy • 144 

44.  Panhysterectomy 145 

45.  Abdominal    panhysterectomy 146 

46.  Closure   of   vagina   in    panhysterectomy *47 

47.  Panhysterectomy 148 

48.  Peritonealization   following   supravaginal   or   panhysterectomy 149 


xiv  ILLUSTRATIONS 

FIGURE  PAGE 

49.  Peritonealization  by  the  use  of  the  sigmoid  colon  to  cover  raw  areas  in  the 

pelvis  after  hysterectomy 150 

50.  Kelly's  left  to  right  method  of  hysterectomy 151 

51.  Doyen's    panhysterectomy 153 

52.  Doyen's   panhysterectomy 154 

53.  Pregnancy  with  multiple  intramural  fibroids 157 

54.  Fibroid    in    position    to    cause    dystocia 159 

55.  Interior  of  uterus  shown  in  Figure  54 161 

56.  Cystic  adenomyoma  with  numerous  nodules  and  subperitoneal  cysts   .        .        .  166 

57.  Adenomyoma  of  posterior  uterine  wall 170 

58.  Everting  squamous  cell  carcinoma  of  cervix  with  cancerous  polyp  ....  188 

59.  Occlusion  of  cervical  canal  by  a  squamous  cell  carcinoma  with  vaginal  metastasis  194 

60.  Inverting  adenocarcinoma  of  cervix  with  extensive  invasion 195 

61.  Extension  of  cancerous  masses  through  peritoneum  of  right  broad  ligament.        .  198 

62.  Exposure  and  ligation  of  the  uterine  artery 230 

63.  Exposure  and  freeing  of  the  ureter 231 

64.  Removal  of  the  parametrium  from  under  the  ureter 232 

65.  Raw  surfaces  after  removing  uterus  and  parametrium 233 

66.  Drainage  after  removal  of  uterus  and  parametrium 234 

67.  Recurrence  of  cancer  ten  weeks  after  cervical  amputation 248 

68.  Chorio-epithelioma 312 

69.  Multilocular  pseudomucinous  cyst  of  ovary 334 

70.  Papillary   serous    cystadenoma .  337 

71.  Solid  ovarian  cancer,   scirrhous  type         .       . 343 

72.  Solid  ovarian  carcinoma,  medullary  type 344 

73.  Solid  ovarian  carcinoma,  medullary  type- 345 

74.  Dermoid  cyst  of  ovary 364 


PELVIC  NEOPLASMS 


PELVIC  NEOPLASMS 

CHAPTER  I 

BENIGN  TUMORS  OF  OUTLET 

Fibroma  of  vulva — Classification — Etiology — Appearance  and  size — Degenerations — Symp- 
toms— Diagnosis— Treatment — Literature — Lipoma  of  vulva — Etiology — Location  and 
appearance — Rate  of  growth — Symptoms — Diagnosis — Treatment — Literature — Sweat 
gland  tumors — Classification — Etiology — Histology — Size,  appearance  and  location — 
Symptoms — Question  of  malignancy — Diagnosis — Treatment — Literature — Cysts  of 
hymen — Frequency — Size  and  appearance — Histology — Etiology— Symptoms — Treat- 
ment— Other  benign  tumors. 

FIBROMA  OF  THE  VULVA 

Fibroma  of  the  vulva  is  the  most  common  of  the  solid  benign 
tumors  in  this  region,  yet  its  rarity  is  shown  by  the  fact  that  there 
are  less  than  175  cases  reported  in  the  literature.  Since  many  men 
have  observed  cases  which  have  not  been  recorded,  the  comparative 
infrequency  of  the  growth  may  be  shown  better  by  Leonard's  report  of 
only  six  fibroid  tumors  of  the  vulva  found  in  23,000  gynecological 
admissions  to  the  Johns  Hopkins  Hospital.  We  have  met  with  only 
one  case  in  the  last  1,200  gynecological  cases  at  the  University  of  Cali- 
fornia hospitals. 

Classification. — Under  the  general  heading  of  fibroma  of  the  vulva 
are  grouped  not  only  the  various  fibroids  which  develop  in  that  structure,  but 
also  the  fibroids  which  develop  elsewhere,  and  which  later  in  their  growth 
find  their  way  by  extension  into  the  vulva.  Naturally  the  great  majority 
of  the  latter  group  have  originated  in  the  round  ligament.  A  considerable 
number  have  developed  from  connective  tissue  deeper  in  the  pelvis.  This 
classification,  while  not  correct  at  first  sight,  has  the  justification  that  the 
great  majority  of  tumors  of  the  round  ligament  develop  in  the  extra- 
peritoneal  portion  of  the  structure  and  are  forced  outward  as  they  grow. 
Thus  Emanuel,  in  1903,  states  that  of  his  80  cases  of  tumors  of  the  round 
ligament  only  20  developed  intra-abdominally,  while  the  other  60  were 
found  either  in  the  inguinal  canal  or  in  the  labia.  In  the  same  manner, 
the  tumors  which  develop  from  the  pelvic  fascia  and  deep  connective  tissue 
find  their  way  through  the  natural  planes  of  cleavage  to  the  external  gen- 
italia.  This  classification,  therefore,  seems  rational  for  the  purposes  of 
the  present  chapter. 


2  PELVIC   NEOPLASMS 

Comparatively  few  men  in  recent  time  have  reviewed  the  literature. 
Supplemental  to  Emanuel,  Taussig,  in  1914,  presented  his  study  of  tumors 
of  the  round  ligament  and  collected  90  extra-abdominal  cases  which  he 
presented  as  vulvar  growths.  Later,  in  1917,  Leonard  tabulated  131  cases 
of  vulvar  fibroids  collected  from  the  literature,  although  it  appears  that 
several  cases  cited  by  Emanuel  and  Taussig  are  not  included  in  the  compila- 
tion. We  quote  Leonard's  table,  not  only  to  show  the  various  points  of 
origin  of  the  growths  classed  as  vulvar  fibroids,  but  also  to  show  the  relative 
frequency  of  the  various  types  which  have  been  encountered. 
Leonard's  table. — 

1.  Fibroid  tumors  originating  in  the  subcutaneous  connective  tis- 
sue ...  70  cases. 

(a)  Labium  majus 53  cases 

(b)  Labium  minus 1 1   cases 

(c)  Vestibule  and  vagina 5  cases 

(d)  Perineum   i  case 

2.  Fibroid  tumors  originating  in  the  extraperitoneal  portion  of  the 
round  ligament  ...  39  cases. 

(a)  Growing  outward  into  the  labium 25  cases 

(b)  Remaining  within  the  canal 1 1   cases 

(c)  Growing  backward  into  the  abdomen 2  cases 

(d)  Growing  up  between  the  layers  of  the  abdominal  wall,    i   case 

3.  Fibroid  tumors  originating  in  the  subperitoneal  connective  tissue 
and  appearing  at  the  vulva  ...  14  cases. 

4.  Fibroid  tumors  originating  in  the  connective  tissue  of  Bartholin 
glands  ...  2  cases. 

5.  Fibroid  tumors  originating  in  hematoma  ...  2  cases. 

6.  Fibroid  tumors  originating  in  the  connective  tissue  of  the  recto- 
vaginal  septum  ...  2  cases. 

Etiology. — The  etiology  is  not  known.  As  shown  in  the  classifica- 
tion cited  above,  the  tumors  may  develop  from  the  subperitoneal  connective 
tissue,  the  extraperitoneal  portion  of  the  round  ligament,  connective  tissue 
of  muscle  fibers  of  the  vulva  and  perineum.  Some,  as  Morestin,  have  ad- 
vanced the  view  that  a  fibroma  may  develop  during  the  organization  of  a 
hematoma.  Kewisch  claimed  that  they  may  arise  from  either  the  pelvic 
fascia  or  the  periosteum  of  the  pelvic  bones;  and  Fromme,  von  Reckling- 
hausen  and  others  hold  that  they  could  originate  in  the  connective  tissue  of 
Bartholin's  gland.  'Others,  as  Taussig,  with  whom  we  agree,  hold  that  the 
great  majority  of  these  tumors  spring  from  structures  of  the  round  liga- 
ment, and  that  many  of  the  glandular  tumors  of  earlier  times  would  have 
been  diagnosed  at  present  as  adenomyoma. 


BENIGN    TUMORS   OF    OUTLET  3 

Trauma  has  been  advanced  as  a  predisposing  factor,  especially  in  the 
cases  which  first  presented  as  hernias  and  which  wore  trusses.  While  this 
view  cannot  be  denied,  it  seems  more  likely  that  the  supposed  hernias  were 
in  reality  tumors  in  their  earlier  stages  which  were  stimulated  to  more 
rapid  growth  by  pressure  of  the  trusses. 

More  striking  is  the  fact  that  nearly  all  of  these  tumors  occur  in  women 
during  the  child-bearing  age,  the  great  majority  of  them  being  between  the 
ages  of  25  and  38.  The  tumors  may,  however,  develop  after  the  meno- 
pause, and  Esser,  Polaillon,  Weber,  and  many  others  have  presented 


FIG.    i. — FIBROMA  OF  THE  LABIUM   MAJUS  RESEMBLING  SCROTUM    (Leonard). 

examples.  Von  Winckel's  round  ligament  tumor  was  found  in  a  woman 
of  76.  On  the  contrary,  Aichel,  in  1912,  noted  one  in  a  newly  born  child, 
and  Goldreich,  in  1909,  described  a  pedunculated  fibroid  on  the  labium  of 
a  nursing  infant. 

Appearance  and  Size. — The  tumor  usually  appears  as  a  small,  firm, 
smooth,  round  or  oval  nodule  immediately  under  the  skin  of  the  labia,  under 
which  it  moves  freely.  Occasionally  it  is  multilocular.  There  may  be 
multiple  growths.  The  overlying  skin  is  generally  thick,  and  in  the  resting 
periods  of  the  tumor's  growth  is  frequently  thrown  into  shallow  folds 
suggesting  the  scrotum.  The  remarkable  resemblance  which  the  nonpedun- 
culated  tumors  of  the  labium  majus  bear  to  the  scrotum  (Fig.  i)  is  fre- 
quently commented  upon  in  the  literature.  The  smaller  tumors  are  gen- 
erallv  either  contained  in  the  labia  or  have  a  sessile  base.  Later  in  their 


4  PELVIC  NEOPLASMS 

growth  they  (especially  the  tumors  arising  below  the  inguinal  ring)  develop 
a  pedicle  which  may  be  of  considerable  length  (Fig.  2).  Both  the  tumors 
and  the  stalk  of  the  growths  arising  in  the  labium  majus  are  frequently 
covered  with  hair. 

Not  all  tumors,  however,  present  this  rather  characteristic  appearance. 
Occasionally  some  present  an  entirely  different  appearance,  as  did  the  case 
of  Kirchoff.  This  tumor  was  projected  from  the  vagina  of  a  girl  of 
eighteen  years,  when  it  was  found  to  be  an  ulcerated,  edematous,  hemor- 


FIG.  2. — FIBROMA  OF  LABIUM  MAJUS  WITH  WELL-DEVELOPED  PEDICLE  (Leonard). 


rhagic  mass  of  fibrosarcomatous  nodules  attached  by  a  broad  pedicle  to  the 
right  labium  minus  (Fig.  3). 

Tumors  which  begin  in  the  inguinal  canal  often  dissect  their  way 
upwards  between  the  layers  of  .the  abdominal  wall  and  form  masses  which 
at  first  sight  are  considered  intraperitoneal  neoplasms.  The  tumors  are 
usually  firm,  although  many  present  a  semisolid  or  even  fluctuating  con- 
sistency as  a  result  of  edema  or  of  sarcomatous  changes.  Even  the  solid 
tumors  give  an  altered  feel  when  the  patient  is  menstruating,  because  of  the 
alterations  in  the  circulation  of  the  growth  at  that  time.  Penrose  states 
that  they  may  swell  to  twice  their  usual  size  during  the  menstrual  period  and 
return  soon  after  to  their  former  size  and  firm  consistency.  Many  have 
emphasized  the  fact  that  the  growth  also  becomes  soft  and  semifluctuant 
during  pregnancy,  during-  which  time  it  grows  with  astonishing  rapidity, 


BENIGN  TUMORS  OP  OUTLET  $ 

doubtless  from  processes  similar  to  those  which  occur  in  uterine  fibroma 
during  pregnancy.  The  folds  and  wrinkles  in  the  skin  become  obliterated 
from  edema  so  that  the  skin  surfaces  surmounting  the  tumor  are  smooth 
and  shiny.  Ulcerations  frequently  appear  at  that  time  and  soon  become 
infected.  When  the  tumor  presents  sarcomatous  changes,  ulceration  is 
extremely  common. 

•  Emanuel  found  that  the  great  majority  of  his  collected  cases  were  on 
the  right  side,  but  later  compilers  have  not  noted  similar  results. 


FIG.  3. — FIBROID  OF  LABIUM  WITH  SARCOMATOUS  DEGENERATION   (redrawn  from  Kirchoff). 

The  size  of  the  growths  varied  greatly,  ranging  from  small  nodules 
to  tumors  of  enormous  size.  Perewaloff  described  a  31 -pound  tumor  mass 
of  the  labium  majus  which  hung  from  its  pedicle  down  to  the  knees.  Grimes 
removed  a  sloughing  mass  of  similar  location  which  weighed  16^2  pounds. 
The  great  majority  of  labial  tumors,  however,  are  smaller,  averaging  the 
size  of  a  hen's  egg.  Tumors  of  the  labium  minus  are  generally  smaller. 
Grigorowitsch's  case  appears  to  be  the  largest,  a  number  of  small  tumors 
surrounding  a  mass  which  weighed  740  grams. 

Tumors  which  originate  in  the  submucous  connective  tissue  of  the  vesti- 


PELVIC   NEOPLASMS 


bule  and  vagina  are  usually  small,  yet  the  fibroid  reported  by  Newman 
grew  from  the  perineum  and  was  the  size  of  a  fetal  head. 

The  subperitoneal  fibroma  is  more  uniformly  of  large  size  and  more 
likely  to  be  muliple  (Fig.  4).  Esmarch  records  a  case  of  a  woman  of  thirty 
who  presented  simultaneously  a  pedunculated  tumor  of  the  right  labium  the 
size  of  a  child's  head ;  a  pedunculated  mass  hanging  from  the  right  buttock 
the  size  of  a  man's  head ;  and  a  fist-sized  tumor  in  the  right  inguinal  region. 
Gallet's  case  is  also  worth  citing.  A  woman  of  thirty-eight  with  a  large 
tumor  of  the  left  labium  majus;  a  tumor  of  the  size  of  a  man's  head  on  the 
left  buttock;  and  just  above  it  a  smaller  tumor  of  the  same  nature.  At 


FIG.  4. — PEDUNCULATED  MULTIPLE  FIBROMA. 

operation,  the  vulvar  tumor  was  found  to  spring  from  a  pedicle  which 
continued  up  beneath  the  ramus  of  the  pubes.  The  smaller  tumor  of  the 
buttocks  hung  from  a  pedicle  coming  out  of  the  obturator  foramen.  The 
patient  died,  and,  at  autopsy,  the  pedicles  of  all  three  tumors  were  found 
to  connect  with  a  similar  tumor  which  was  not  connected  with  the  pelvic 
organs  in  any  way.  The  tumors  were  fibromatous,  containing  many  cystic 
cavities. 

Buckner's  case,  described  in  1851,  is  of  striking  interest  in  that  the 
tumor  masses  were  estimated  to  weigh  268  pounds,  which,  with  the  possible 
exception  of  Spohn's  and  Barlowe's  mammoth  ovarian  tumors,  is  the  largest 
neoplasm  of  which  we  have  record  (Fig.  5).  While  the  details  of  this 
case  are  not  entirely  clear,  it  is  of  sufficient  interest  to  warrant  the  quotation 
of  Buckner's  notations. 


BENIGN    TUMORS   OF   OUTLET 


In  1843,  a  married  woman,  aged  twenty-five  years,  gave  birth  to  a  still- 
born child  at  term.  This  was  her  fourth  pregnancy.  Following  it  there 
was  difficulty  in  passing  urine,  and  the  catheter  was  used  for  some  months. 
At  this  time  a  soft,  immovable  tumor  was  felt  a  little  to  the  right  of  the  linea 
alba,  almost  filling  the  right  side  of  the  abdomen.  It  increased  rapidly. 
Four  years  later  (1847),  anothei  tumor  appeared  in  the  right  labium  extend- 


FIG.  5. — MAMMOTH  FIBROMA  (drawn  from  Buckner's  daguerreotype). 

ing  to  the  nates.  Jt  was  soft  and  elastic,  and  for  a  year  or  two  could  be 
returned  to  the  abdomen.  It  subsequently  enlarged  as  the  abdominal  tumor 
did,  and  fluctuated  so  distinctly  as  to  be  mistaken  for  a  case  of  dropsy. 
These  tumors  were  tapped  or  incised  eight  times,  but  no  fluid  was  dis- 
charged. The  growth  caused  most  distressing  symptoms,  and  the  patient 
could  hardly  breathe  except  upon  her  hands  and  knees.  But  with  the 
enlargement  of  the  tumor  of  the  buttock,  the  dyspnea  was  relieved  as  well 
as  a  general  anasarca  and  numbness  of  the  legs.  At  the  request  of  the 


8  PELVIC   NEOPLASMS 

patient  this  growth  was  opened  and  the  finger  introduced,  but  a  soft  tissue, 
like  the  omentum,  was  all  that  could  be  felt. 

A  year  later  (1848)  she  became  pregnant  again,  and  was  delivered  at 
full  term,  by  artificial  means,  of  a  child  which  died  during  labor.  It  must 
have  been  indeed  a  case  of  "mons  laborat,"  and  many  difficulties  must  have 
been  surmounted  at  the  time  of  conception,  for  it  is  stated  that  before  this 
last  pregnancy,  when  she  was  in  a  sitting  posture,  which  she  sometimes  at- 
tempted, the  abdominal  tumor  rested  upon  her  thighs  as  far  as  her  knees, 
and  the  tumor  of  the  hip  was  fifteen  inches  long,  ten  inches  in  greatest  diam- 
eter and  four  inches  at  the  point  of  its  connection  with  the  perineo-ischiatic 
region. 

In  1850,  two  years  later,  the  patient  weighed  269  pounds.  As  her  great- 
est weight  before  marriage  was  108  pounds,  and  as  her  flesh  was  greatly 
reduced,  it  was  estimated  that  the  entire  growth  was  about  180  pounds. 

In  1851,  Dr.  Buckner  traveled  220  miles  to  see  her,  taking  with  him  a 
daguerreotypist. 

At  that  time,  the  circumference  of  the  abdomen  was  seven  feet  six  inches 
and  the  distance  from  the  ensiform  cartilage  to  the  pubes  was  three  feet  six 
inches.  The  tumor  of  the  buttock  extended  along  the  thigh,  and  measured 
two  feet  six  inches  in  length  and  eighteen  inches  transversely. 

There  was  some  pustular  eruption  on  the  skin  over  the  ischiatic  tumor,  but 
in  general  her  health  was  good  and  her  functions  well  performed.  Menstrua- 
tion was  regular  as  to  time  and  quantity,  although  painful  during  the  last 
few  years. 

Towards  the  close  of  1853  the  cutaneous  affection  increased,  her  health 
failed,  and  she  died  January,  1854,  at  the  age  of  thirty-six,  and  eleven  years 
after  the  disease  was  first  noticed. 

An  autopsy  was  not  allowed,  but,  in  order  to  get  her  into  some  sort  of  a 
coffin,  the  attending  physician  removed  the  posterior  tumor  in  the  presence  of 
her  husband.  Within  it  was  a  cavity  into  which  his  arm  could  be  passed  to  the 
elbow.  He  then  passed  his  arm  upward  into  the  pelvis  and  abdomen,  and,  with 
the  other  hand  upon  the  tumor  externally,  he  satisfied  himself  that  the  abdom- 
inal and  pelvic  viscera  were  intact,  and  that  the  tumor  was  external  to  the 
peritoneal  cavity.  The  cavity  in  the  posterior  tumor  was  a  process  of  the 
peritoneum ;  the  two  tumors  were  portions  of  one  and  the  same  growth,  and 
the  point  of  egress  was  through  the  ischiosciatic  notch. 

The  growth  removed  consisted  mainly  of  a  soft,  adipose  structure  inter- 
spersed with  delicate  layers  of  fibrous  tissue,  in  bulk  enough  to  fill  a  common 
washtub,  and  the  entire  mass  of  both  growths  was  estimated  to  be  about  268 
pounds. 

The  rate  of  growth  is  usually  extremely  rapid,  although  occasionally  it 
is  fairly  slow.  Sometimes  a  tumor  grows  slowly  for  a  considerable  length 
of  time  and  then,  without  known  reason,  assumes  remarkable  activity  of 
growth.  Bigelow's  tumor  grew  to  the  size  of  a  coconut  within  three  years, 
while  MacEwen's  tumor  required  nine  years  to  attain  the  weight  of  three 
pounds.  The  growth  is  stimulated  to  remarkable  activity  during  pregnancy, 
during  which  time  it  may  attain  very  large  size.  The  effect  of  menstruation 
upon  the  rate  of  growth  has  already  been  considered. 


BENIGN    TUMORS   OF   OUTLET 


Degenerations. — Fibroid  tumors  of  the  vulva  are  said  to  be  more 
likely  to  undergo  degenerative  processes  than  similar  tumors  in  other 
parts  of  the  body.  Two  factors  are  chiefly  responsible:  (i)  the  marked 


FIG.  6. — EDEMATOUS  FIBROMA  (drawn  from  Harrington). 

variations  in  the  blood  supply  during  menstruation  and  pregnancy; 
and  (2)  the  fact  that  the  tumor,  when  growing  rapidly,  soon  becomes 
pedunculated,  also  often  with  circulatory  disturbances. 

Edema  is  most  common  (Fig.  6).     The  tumor's  surfaces  are  also 


I0  PELVIC   NEOPLASMS 

very  likely  to  suffer  abrasions  which,  because  of  an  unbalanced  circula- 
tion, soon  become  ulcerated  with  resulting  infection.  Gangrene  may 
result.  Hyaline  degeneration  is  very  common  as  are  cystic  changes. 
Calcification  is  frequently  observed  and  lymphangiectases  have  been 
described.  Many  of  the  tumors  are  classed  as  myxofibroma. 

Most  interesting,  however,  is  the  tendency  to  sarcomatous  changes. 
Leonard,  in  his  careful  review,  states  that  nearly  one-fifth  of  the  cases 
reviewed  by  him  had  undergone  sarcomatous  changes. 

Symptoms. — Even  the  larger  sessile  fibroma  of  the  vulva  rarely 
produces  symptoms  of  pain  or  pressure  or  causes  inconvenience  other 
than  chafing  of  the  enlarged  labium,  save  during  menstruation  or 
pregnancy.  Occasionally,  itching  is  a  prominent  symptom.  The 
fibroids  which  develop  in  the  rectovaginal  septum  may  cause  constipa- 
tion, and  in  a  case  reported  by  Villiers  and  Damoge,  retention  of  urine 
was  deemed  to  have  resulted  from  pressure  of  the  calcified  fibroid  of 
the  vestibule  on  the  urethra.  The  larger  pedunculated  fibroids  cause 
symptoms  from  weight  alone  and  may,  from  their  size,  interfere  with 
locomotion.  Coates  reports  a  case  in  which  coitus  was  practically 
impossible,  and  Albert  records  one  which  interfered  with  parturition. 
The  changes  during  menstruation  have  been  alluded  to  above.  When 
a  tumor  becomes  swollen  and  edematous,  ulcerations  are  likely  to  fol- 
low, and  in  the  event  of  secondary  infection,  which  is  usual,  the  growth 
becomes  very  sensitive.  If  the  tumor  undergoes  malignant  change, 
which  is  a  frequent  occurrence  (one-fifth  of  the  cases  collected  by 
Leonard),  ulceration  is  the  rule.  Such  tumors  may  be  exquisitely 
sensitive. 

Nonpedunculated  tumors  in.  the  inguinal  canal  may  give  rise  to 
pressure  symptoms  and  in  addition  to  producing  a  dragging  sensation, 
may  cause  pains  radiating  down  the  thigh. 

Diagnosis. — The  diagnosis  offers  no  difficulty,  although  the  origin 
of  the  tumor  may  not  always  be  determined  until  its  removal.  The 
fibroma  developing  in  the  extraperitoneal  portion  of  the  round  liga- 
ment has  led  to  the  most  frequent  errors  of  diagnosis.  Quite  naturally 
they  are  likely  to  be  mistaken  for  an  inguinal  hernia,  as  has  been  noted 
by  Heidemann,  von  Recklinghausen,  Verneuil,  and  others.  The  case 
reported  by  Doormann  had  worn  a  truss,  until  the  size  of  the  growth 
demanded  surgical  interference.  These  errors  are  not  surprising,  since 
a  tumor  in  this  region  usually  simulates  an  inguinal  hernia.  Moreover, 
tumors  of  the  round  ligament  are  sometimes  associated  with  inguinal 
hernias,  as  is  evidenced  by  the  cases  of  Hecker,  Hofmarkel,  Landau 
and  others.  The  tumor  reported  by  Nebesky  was  actually  reducible 
through  the  inguinal  canal.  In  at  least  one  case  (Coates)  the  round, 
firm,  elastic  mass  was  mistaken  for  a  testicle  and  the  diagnosis  was  held 
to  be  hermaphroditism. 

The  differentiation  from  irreducible  omental  hernias,  from  hvdro- 


BENIGN   TUMORS   OF    OUTLET  n 

cele  muliebrum  and  from  glandular  masses  is  often  attended  with  dif- 
ficulty. In  Klemen's  7  cases,  the  correct  diagnosis  was  made  only  three 
times  before  operation. 

Treatment. — The  treatment  is  surgical  removal,  necessary  even  in 
cases  which  are  not  giving  symptoms,  because  of  the  likelihood  of  sar- 
comatous  change.  The  fact  that  the  tumors  classed  as  sarcomata  have 
appeared  benign  clinically  (we  have  not  found  a  case  which  presented 
metastases),  in  no  way  invalidates  this  statement. 

The  result  of  removal  is  usually  good  and  there  are  few  deaths 
recorded  after  operation.  There  are  no  recurrences  after  removal. 
Other  tumors,  however,  may  subsequently  appear  in  the  same  region 
just  as  new  fibroids  may  form  after  myomectomy.  There  are  a  number 
of  such  cases  in  the  literature,  chiefly  subperitoneal  connective  tissue 
or  extraperitoneal  round  ligament  fibroids. 


LIPOMA    OF   THE   VULVA 


Lipoma  of  the  vulva  is  rarely  met  with.  This  seems  surprising, 
because  lipoma  in  general  is  so  common.  The  infrequency  of  these 
cases  is  well  shown  by  the  fact  that  no  operator  has  yet  recorded  more 
than  a  single  case  in  his  own  experience.  Kelly,  in  1903,  collected  19 
cases  from  the  literature  and  added  a  case  of  his  own.  Since  then, 
some  8  or  10  cases  only  have  been  recorded,  of  which  we  cite  the  cases 
of  Hill,  Fenno,  Hutchinson,  Olivieri,  Carmalt  and  Sturmdorff.  Prior 
to  Kelly's  paper,  no  author  had  collected  more  than  3  or  4  cases. 

This  class  of  tumors  is  worthy  of  consideration  chiefly  because  they 
may  attain  considerable  size.  Degenerations  of  clinical  importance 
are  not  common.  The  tumors  do  not  appear  to  undergo  malignant 
change.  We  know  little  as  to  the  etiology  save  that  they  occur  usually 
during  the  child-bearing  age. 

Location  and  Appearance. — Lipoma  in  this  region  occur  either  on 
the  labium  majus,  or  the  mons  veneris,  and  present  the  same  character- 
istics as  lipoma  elsewhere.  They  are  usually  soft,  but  may  be  firm, 
since  their  feel  depends  upon  the  relative  proportions  of  fat  and  con- 
nective tissue  in  the  growth.  The  fat  may  be  encapsulated,  yet  is  more 
usually  diffuse. 

The  tumors  may  be  contained  in  the  enlarged  labia  or  mons,  or 
may  project  from  it  by  a  large  base.  Later  in  their  growth,  they  may 
sink  down  by  their  weight,  drawing  the  skin  out  in  the  form  of  a 
pedicle.  Rarely  they  grow  up  toward  the  inguinal  canal  and  simulate 
a  hernia,  as  in  the  case  of  de  Smet  (Fig.  7). 

The  skin  surmounting  the  tumor  usually  appears  normal,  yet  may 
be  tightly  drawn  over  it,  or  may  be  wrinkled  or  even  lobulated.  As  a 


12 


PELVIC   NEOPLASMS 


result  of  friction,  it  may  thicken  or  sometimes  ulcerate.  Occasionally 
the  surface  of  the  growth  is  covered  by  tortuous  telangiectasis.  The 
blood  vessels  in  the  skin  are  usually  enlarged  and  may  occasion  severe 
hemorrhage  if  ulceration  is  extensive,  as  well  as  in  the  rare  cases  in 
which  the  patients  attempt  removal.  Koch  reports  such  a  case  which 
came  to  his  attention  because  of  the  very  severe  h'emorrhage  which 
followed  the  woman's  attempt  to  cut  off  the  growth  with  a  razor.  In 
the  same  manner,  Deekens  records  his  case  which  had  lost  a  quart  of 
blood  from  the  ulceration  two  weeks  before  operation. 

Growth. — The  rate  of  growth  is  usually  slow,  in  marked  contrast 
to  fibroids  of  the  vulva.  Deekens'  case,  a  woman  of  sixty-one,  had 
carried  the  slow-growing  tumor  for  seventeen  years  before  ulceration 


FIG.  7. — LIPOMA  OF  LEFT  LABIUM  SIMULATING  A  HERNIA  (drawn  from  Goodell). 

and  the  ensuing  hemorrhage  forced  her  to  seek  treatment.  There  are 
numerous  cases  in  which  the  growth  was  carried  ten  years.  The  state- 
ment made  in  numerous  texts,  that  the  tumor  grows  rapidly  during 
menstruation  and  pregnancy,  is  not  substantiated  by  our  review  of 
cases,  in  which  the  very  great  majority  were  found  in  women  during 
the  child-bearing  period. 

Yet  the  tumor  may  attain  considerable  size.  Balls-Headley's  case 
is  the  largest,  weighing  twenty-four  pounds:  a  number  of  other  cases 
have  weighed  ten  pounds,  although  the  usual  size  is  the  "size  of  a 
fist." 


BENIGN  TUMORS  OF  OUTLET  13 

Symptoms. — The  symptoms  depend  largely  upon  the  size  and 
position  of  the  growth.  Smaller  tumors  may  cause  no  symptoms,  or 
at  worst,  only  symptoms  from  friction.  The  larger  tumors  may  occa- 
sion dragging  sensations  from  the  weight  of  the  growth,  and  inter- 
ference with  locomotion.  Several  complained  of  difficulty  in  coitus. 
Bountzel's  case  was  the  size  of  a  fist  for  four  years,  enlarged  during 
labor  to  the  size  of  a  child's  head  and  retarded  labor.  SturmdorfFs  case 
also  partially  blocked  labor  (together  with  an  old  ankylosis  of  the  right 
hip). 

Diagnosis. — The  diagnosis  may  be  confusing.  The  soft  tumors 
may  be  readily  mistaken  for  cysts.  Goodell's  case  was  explored  for 
fluid  with  the  needle  without  result  before  the  diagnosis  was  made. 
Many  others  gave  a  sense  of  false  fluctuation,  notably  de  Smet's,  and 
Henningsen's.  The  growth  may  be  confused  with  a  hernia.  Balls- 
Headley's  case  was  not  only  fluctuant,  but  the  impulse  on  coughing  was 
conveyed  to  the  labial  growth  weighing  24  pounds.  Lipoma  has  also 
been  confused  with  elephantiasis,  cysts,  adrenal  rests  (Andrews)  and 
fibroma. 

Treatment. — The  growth  can  be  removed  without  difficulty,  shell- 
ing out  the  entire  fatty  capsule.  After  all  bleeding  points  are  ligated, 
raw  surfaces  should  be  approximated  and  the  incision  should  be  united 
with  horsehair  sutures. 


SWEAT  GLAND  TUMORS  OF  THE  VULVA 

Sweat  gland  tumors  of  the  vulva  have  been  found  so  seldom  that 
they  may  be  counted  as  among  the  very  rare  neoplasms  of  this 
structure.  There  are  only  some  20  cases  which  have  been  described, 
although  the  growth  is  usually  so  small,  and  causes  symptoms  so 
rarely,  that  it  is  quite  likely  that  it  occurs  far  more  frequently  than 
these  figures  suggest. 

Braun,  in  1892,  described  the  first  case  of  which  we  have  record 
in  which  the  diagnosis  was  correctly  made,  yet  his  observation  created 
little  interest,  and  it  was  not  until  Pick,  in  1904,  presented  his  study 
that  the  attention  of  pathologists  was  directed  to  this  rare  tumor. 
Nearly  all  the  cases  reported  have  been  observed  in  Europe.  Thus  far 
only  the  cases  of  Outerbridge  and  Schwarz  have  been  reported  from 
America. 

Classification. — L.  Pick,  in  1904,  after  a  careful  and  painstaking 
study  of  his  2  cases,  and  a  review  of  the  few  cases  then  present  in  the 
literature,  concluded  that  we  should  distinguish  carefully  between  the 
tumors  which  presented  indisputable  points  of  origin  from  the  vulvar 
sweat  glands  (hidradenoma  tubulare)  from  those  in  which  the  origin 


PELVIC   NEOPLASMS 


could  not  be  definitely  proven  (adenoma  hidradenoid),  even  though 
both  types  of  tumor  presented  certain  similar  histologic  features. 

The  hidradenoma  tubulare,  as  the  name  implies,  is  an  adenomatous 
structure  containing  acini  lined  with  a  double  layer  of  cells  which  are 
supported  by  elastic  tissue,  the  whole  mass  being  inclosed  by  a  definite 
membrana  limitans  of  elastic  tissue.  A  sudoriferous  duct  originating  in 
the  adenoma  can  be  traced  to  its  opening  in  the  skin. 

Adenoma  hidradenoid  presents  rather  similar  histology,  yet  proof 
of  its  origin  from  completely  developed  sweat  glands  is  lacking  in  that 


D 


FIG.  8. — SWEAT  GLAND  TUMOR  OF  VULVA.     Low  power  photograph  of  section  through 
entire  tumor  and  surrounding  tissues  (Outerbridge). 

there  is  no  sudoriferous  duct,  nor  connection  with  other  sweat  glands. 
Some,  as  Landsteiner  and  Outerbridge,  have  objected  to  this  classifica- 
tion on  the  ground  that  it  is  complicated  and  suggest  the  term 
"hidradenoma"  to  designate  all  adenomatous  tumors  presenting  a  histo- 
logic picture  suggesting  sweat  glands.  Practically  all  the  cases  in  the 
literature,  however,  are  reported  on  the  terms  of  Pick's  classification. 
There  is  no  essential  difference  between  the  solid  and  cystic  type 


BENIGN    TUMORS   OF    OUTLET  15 

of  cases,  since  the  latter  arise  from  the  former  by  accumulation  of  the 
secretion  of  the  glandlike  tumor. 

Etiology. — Little  is  known  of  the  etiology,  besides  the  fact  that 
these  tumors  originate  in  vulvar  sweat  glands.  The  cases  presenting 
for  treatment  have  all  been  older  than  thirty-five,  although  many  of  the 
growths  were  first  noted  in  the  twenties. 

Histology. — The  hidradenomata  are  usually  situated  in  the  corium, 
and  are  composed  of  adenomatous  or  papillary  structures  containing 
innumerable  irregular  acini  and  tubules,  separated  by  exceedingly 
delicate  connective  tissue  septa.  The  acini  are  lined  in  many  places 
by  a  double  layer  of  nonciliated  cells,  an  inner  layer  of  high  cylindrical 


FIG.  9. — SWEAT  GLAND  TUMOR  OF  VULVA.     High  power,  through  areas  at  b,  Fig.  8, 
showing  cystic  acini  and  squamous  epithelium  of  epidermis. 

cells  surmounting  a  layer  of  shorter  and  more  irregularly  shaped  cells. 
Each  acinus  is  surrounded  by  a  definite  layer  of  elastic  tissue.  In  some 
places,  the  superficial  squamous  epithelium  of  the  labium  sends  down 
long  prolongations  which  communicate  with  the  acini  of  the  tumor. 
The  tumor  is  usually  well  limited  within  its  bounding  membrane  of 
elastic  fiber,  yet  the  cases  of  H.  Ruge,  Outerbridge  (Figs.  8,  9)  and 
Schwarz  have  presented  areas  of  its  invasion. 

Size,  Appearance  and  Location. — The  growth  is  usually  of  small 
size,  frequently  described  as  "pea  size,"  or  "cherry  stone  size,"  and  only 
Schroeder's  case  was  as  large  as  a  walnut.  It  usually  presents  as  a 
subcutaneous  circumscribed  neoplasm  which  may  be  either  firm  or 


1 6  PELVIC   NEOPLASMS 

cystic,  although  it  has  been  described  as  a  broad,  pedicled,  mushroom- 
shaped  tumor  (case  of  Pick).  It  is  covered  with  skin  which  may  be 
ulcerated  from  the  trauma  of  continued  friction.  The  tumor  is  usually 
single.  It  may  be  multiple,  as  shown  by  one  of  Pick's  cases,  which  had 
three  tumors,  and  the  case  of  Gross,  which  had  four.  The  growth  may 
appear  in  any  part  of  the  labium  majus  or  minus;  it  has  been  found  as 
high  up  as  the  urethral  orifice,  and  as  low  down  as  the  posterior  com- 
missure. 

Usually  imbedded  in  the  vulva,  it  presents  no  definite  color. 
Williamson's  case,  however,  was  definitely  pink,  probably  from  second- 
ary disturbances  of  circulation,  since  the  growth  was  ulcerated  and 
bled  very  readily  when  touched. 

The  rate  of  growth  is  usually  very  slow.  Many  of  the  tumors  had 
been  known  to  have  been  present  for  ten  years.  Schroeder's  case  had 
had  a  small  cyst  for  ten  years,  which  had  not  grown  noticeably  until  a 
few  weeks  before  coming  for  treatment. 

Symptoms. — The  growth  is  usually  so  small  that  it  does  n®t  cause 
syniptoms,  unless  it  has  begun  to  grow  rapidly,  or  has  become  ulcer- 
ated and  infected. 

Question  of  Malignancy. — The  tumors  are  accounted  benign, 
although  some  question  as  to  the  frequency  of  malignant  changes  or 
features  has  been  raised  by  the  cases  of  H.  Ruge,  Outerbridge,  and 
Schwarz.  Ruge  considered  that  his  case  had  become  carcinomatous, 
although  all  who  have  reviewed  his  work  do  not  agree  with  him.  Out- 
erbridge and  Schwarz  viewed  their  cases  rather  with  suspicion,  since 
the  former  found  acini  which  had  invaded  the  stroma,  while  the  latter 
found  an  extension  of  solid  masses  of  round  or  polyhedral  cells  into  the 
same  structure. 

Diagnosis. — The  diagnosis  may  be  suspected  on  finding  a  small, 
firm  tumor  in  the  labia  attached  to  the  under  surface  of  the  skin.  The 
final  diagnosis  can  be  made  only  with  the  microscope. 

Clinicallv,  sweat  gland  tumors  may  be  confounded  with  small  seba- 
ceous cysts,  with  cysts  originating  from  aberrant  urethral  ducts,  with 
labial  cysts  lined  with  ciliated  epithelium  and  probably  of  embryonal 
origin,  with  cysts  of  the  wolffian  ducts,  and  with  chronic  inflammatory 
conditions  of  Bartholin  glands. 

Treatment. — The  proper  treatment  is  removal,  since  the  number 
of  cases  which  have  been  studied  is  too  few  to  warrant  the  belief  that 
the  tumor  may  not  develop  malignant  tendencies. 

CYSTS  OF  THE  HYMEN 

Cysts  of  the  hymen  are  very  rare.  Gellhorn,  in  his  careful  review 
of  the  literature  up  to  1904,  could  find  but  17  cases,  most  of  which  were 
noted  in  the  newborn.  Rarely  they  occur  in  youth.  They  are  located 


BENIGN   TUMORS   OF   OUTLET  17 

most  frequently  on  the  outer  surface  of  the  hymen  and  generally  are  very 
small.  They  may  attain  the  size  of  a  cherry.  Most  of  the  reported 
cases  are  single  growths.  The  case  reported  by  Ulesko-Stroganowa 
had  a  small  cyst  on  each  side  of  the  hymen.  Ricci's  case  had  a  small 
tumor  included  in  the  wall  of  a  larger  one.  One  of  Ziegenspeck's  cases 
had  two  small  cysts  at  the  base  of  the  main  cyst.  Piering  observed  a 
case  in  which  the  margin  of  the  hymen  was  surrounded  by  a  number  of 
small  transparent  cysts. 

Microscopic  Appearance. — The  covering  is  squamous  epithelium 
derived  from  that  of  the  hymen.  The  stroma  wall  is  composed  of  more 
or  less  dense  connective  tissue  arranged  in  layers,  sometimes  thrown 
into  well-developed  papillae.  Numerous  capillaries  are  present,  occa- 
sionally in  masses  of  smooth  muscle  fibers.  The  inner  surface  of  the 
cyst  wall  is  lined  with  epithelium  which  may  be  of  the  cuboidal  type, 
although  it  is  more  often  of  the  pavement  variety.  Marchesi's  case  was 
lined  with  high  cylindrical  epithelium. 

Histology. — The  cysts  may  contain  a  watery  fluid  or  a  homo- 
geneous jellylike  substance  of  yellowish  brown  color  or  a  mass  of 
epithelial  detritus.  Blood  corpuscles  were  noted  by  U!esko-Stroga- 
nowa.  Ricci's  cyst  was  composed  of  detritus  of  blood  corpuscles,  fat 
droplets,  epithelial  cells  in  large  numbers  suspended  in  the  dark  brown 
liquid. 

Etiology. — Various  theories  have  been  given  to  account  for  the 
origin  of  cysts.  Ricci  has  stated  that  they  may  arise  from  embryonal 
epiblastic  remnants  contained  within  the  stroma.  Bastelberger  ad- 
vanced the  view  that  they  resulted  from  invagination  and  separation 
of  the  epithelium  of  the  hymen.  Doderlein's  view  was  rather  similar 
in  that  he  thought  they  resulted  from  the  coalescence  of  folds  of  the 
hymen.  One  of  Gellhorn's  cases  rather  supports  the  last  view,  since 
fibrous  bands  were  found  extending  out  into  the  hymen  and  separating 
a  mass  of  epithelium.  Some  regard  them  as  retention  cysts.  Piering 
thought  that  they  might  arise  from  distended  lymph  spaces.  Others 
hold  that  they  develop  from  the  glands  which  are  occasionally  found 
in  the  hymen.  Ulesko-Stroganowa  and  Marchesi  thought  that  their 
cases  arose  from  wolrfian  ducts,  since  they  were  lined  with  cylindrical 
epithelium.  Palm  attributed  his  case  to  a  dilatation  of  sebaceous 
glands. 

Symptoms. — Symptoms  depend  upon  the  size  of  the  tumor.  Usually 
the  growth  is  small  and  is  discovered  accidentally. 

Treatment. — The  treatment  is  excision. 

Other  benign  neoplasms  of  the  hymen  are  very  rarely  noted.  Pol- 
ypoid tumors  and  angioma  have  been  described. 


1  8  PELVIC   NEOPLASMS 

OTHER  BENIGN  TUMORS  OF  THE  VULVA 

The  majority  of  these  are  only  pathological  curiosities  and  are 
extremely  rare. 

There  are  few  cases  of  neuroma  of  the  vulva  in  the  literature. 
Simpson  reports  one  in  which  the  tumor  was  a  painful  nodule  situated 
in  the  labia  near  the  urinary  meatus.  Kennedy  reports  a  case  in  which 
the  tumor  presented  as  extremely  tender  tubercles. 

Teliangiectatic  angioma,  chondroma,  and  cysts  have  rarely  been 
encountered. 

LITERATURE 

BRAUN.      Ueber   Endotheliome   der   Haut.      Arch.    f.    klin.    Chir.      1892. 

63:213. 

CARMALT.    Amer.  Jour,  of  Obst.     1902. 
COATES.    Cleveland  J.  of  Med.    January,  1900.     5:24. 
ESSER.    Inaug.  Diss.  Bonn,  1892.    Ref.  Zentralbl.  fur  Gyn.    1892.    16:871. 
FLEISCHMAN.     Beitrag  zur  Kasuistik  des  Adenoma  Hidradenoides  Vulvae. 

Monatsschr.  f.  Geb.  u.  Gyn.    1905.    21  1497 
FROMME.   Monatsschr.  f.  Geb.  u.  Gyn.    1904.   20:  961. 
GEBHARD.    Pathologische  Anatomic  der  weiblichen  Sexualorgane.    Leipzig, 

1899.  .P.  591- 

GELLHORN.    Amer.  Journ.  Obst.    August,  1904. 
GOODMAN.     American  Medicine.    January,  1914.     20:  i. 
GROSS.     Multiple  gutartige  Geschwiilste  der  Vulva  (Adenoma  Hidraden- 

oides).   Ztschr.  f.  Geb.  u.  Gyn.     1907.     60:  565. 
HILL.    Medical  Times  and  Hospital  Gazette.    London,  1894.    22. 

Transactions  of  the  Pathological  Society  of  London.     26:  186. 
HUTCHINSON.     Transactions  of  the  Pathological  Society  of  London.     37. 

London  Hospital  Reports,     i:  121. 
JACOBI.    Archives  Pediatrics.     1894. 
KELLY.     Johns  Hopkins  Hosp.  Reports.     1893.    Vol.  3. 
LANDSTEINER.    Ueber  Tumoren  der  Schweissdriisen.     Beitr.  z.  path.  Anat. 

u.  z.  alg.  Path.  (Ziegler).     1906.     39:  316. 
LEONARD.    J.  H.  Bulletin.    December,  1917.    28:  322. 
MORESTIN.     Bull,  et  mem.  de  la  soc.  anat.  (5me   series).     1898.      12:  526. 
OLIVIERI.     Annals  de  la  Policlinic  de  Paris.     1899.     9:54. 
OUTERBRIDGE.     Sweat-gland  Tumors  of  the  Vulva.     Amer.  Jour.  Obst. 

July,  1915   (No.  i).     72:32. 
PENROSE.    Amer.  Journ.  Obst.     1896.    34:  72. 
PICK.  Ueber  Hidradenoma  und  Adenoma  Hidradenoides.     Virch.  Arch. 


POLAILLON.    Gaz.  Med.  de  Paris.     1891.    No.  32.    7:  377. 


BENIGN   TUMORS   OF   OUTLET  19 

RABL.     Histologie  der  Haut.     Mracek's  Handbuch  der  Hautkrankheiten. 

1901.    Vol.  i. 
RUGE.      Ueber    Vulvaaffektionen    und    ihre    gynakologische    Bedeutung. 

(Schweissdriisenkarzinome).    Ztschr.  f.  Geb.  u.  Gyn.     1905.    56:  307. 
SALA.    Bull,  de  la  soc.  anat.     1856.    P.  107. 
SCHWARZ.     Adenoma  Hidradenoides  Tubulare  Destruens.     Amer.  Jour. 

Obst.  and  Gyn.     April,  1921.     No.  7,  1:695. 
STURMDORFF.      Transactions   of   the   New  York   Academy  of   Medicine. 

Amer.  Jour.  Obst.     1910. 
VON  RECKLINGHAUSEN.     Wiener  klin.  Wochenschr.     1899.     No.  2,   12. 

Quoted  by  Fromme. 

WEBER.    Monatsschr.  f.  Geb.  u.  Gyn.    1899.    9:  591. 
WHITNEY  AND  HARRINGTON.    Annals  of  Surgery.     1905.    61 :  823. 


CHAPTER  II 

MALIGNANT  TUMORS  OF  OUTLET 

Carcinoma  of  vulva — Frequency — Age — Etiology — Appearance  and  structure — Classifica- 
tion— Extension — Symptoms — Diagnosis — Prognosis — Treatment — Results — Carcinoma 
of  the  clitoris — Type  of  growth — Frequency — Etiology — Age — Location — Appearance 
and  form — Histology — Symptoms — Treatment — Carcinoma  of  Bartholin  glands — 
Classification — Etiology — Age — Gross  appearance — Symptoms — Diagnosis — Prognosis 
—Treatment — Literature — Sarcoma  of  the  vulva — Classification — Frequency — Etiology 
— Age — Point  of  origin- — Location  and  appearance  of  growth — Metastasis — Clinical 
picture — Symptoms — Diagnosis — Treatment — Prognosis — Literature. 

CARCINOMA    OF   THE   VULVA 

This  condition  attracts  attention  because  of  its  extreme  malignancy. 
There  are  some,  as  Dittrick,  who  have  made  fairly  extensive  reviews 
of  the  literature  without  finding  record  of  a  single  five-year  cure. 

Frequency. — Vulvar  carcinoma  is  a  rare  disease  in  comparison  with 
carcinoma  in  other  parts  of  the  generative  tract.  When  we  consider 
the  inevitable  trauma  associated  with  child-bearing,  etc.,  it  seems  as  if 
these  tissues  possess  an  increased  resistance  to  malignant  changes. 

The  frequency  of  carcinoma  of  the  vulva  is  variously  stated, 
although  all  emphasize  its  rarity.  Rothschild,  in  1912,  was  able  to  col- 
lect but  395  cases.  Ederle,  in  1919,  found  that  the  series  reviewed  by 
Gurlt,  Schultze,  Engstrom,  Teller,  Frankl,  Lutzenberger,  Ossing,  and 
Rothschild  total  677  cases.  Plater  found  but  8  cases  in  6,407  gyneco- 
logic patients  in  the  University  Frauenklinik  of  Heidelberg  from  1902 
to  1909.  Rothschild  states  that  there  were  only  6  cases  in  9,643 
gynecologic  patients  in  the  Freiburg  University  Frauenklinik  during 
the  years  1904  to  1911.  Combining  the  comprehensive  statistics  of 
L.  Mayer,  Gurlt,  Winckel,  Conner,  Schwarz,  Eisenhart,  Bliimcke,  Tip- 
jakoff,  Lipinski,  and  de  Leon,  Bjorkvist*  found  that  vulvar  carcinoma 
occurred  once  to  821  gynecologic  patients  (0.12  per  cent). 

The  relative  frequency  of  carcinoma  of  the  vulva  and  carcinoma  of 
the  uterus,  including  in  the  latter  the  cancers  of  both  the  cervix  and 
the  uterine  body,  varies  considerably  with  different  observers. 
Virchow  gives  it  as  i  to  40;  Gurlt,  as  i  to  48;  Schwarz,  as  i  to  38; 
Burghele,  as  i  to  35  or  40;  Frankl,  as  i  to  29;  and  Flater,  as  i  to  27. 
The  percentage  which  carcinoma  of  the  vulva  constitutes  of  carcinoma 
of  the  female  genital  tract  varies  considerably.  Von  Winckel,  basing 


21 

his  observations  on  1,068  polyclinic  cases,  found  0.6  per  cent;  Gurlt, 
i  per  cent;  Pissemskz,  1.7  per  cent;  Schottlaender,  2.1  per  cent;  Savare, 
4  per  cent  of  300  pelvic  carcinoma;  and  Conner,  5  per  cent  of  99  cases. 
We  have  seen  7  cases  in  a  series  of  140  pelvic  cancers. 

Jacoby  itemizes  the  incidence  of  355  pelvic  cancers  in  women  as 
follows : 


Pilvic  Cancer 

Cases 

Per  Cent 

Of  uterus  .  .            

317 

80.3 

Of  ovary       

23 

6.? 

Of  vagina      

IO 

2.8 

Of  vulva  

i  .4 

Age. — Carcinoma  of  the  vulva  is  most  often  seen  in  old  age. 
Rothschild,  in  1912,  analyzed  395  cases  of  carcinoma  of  the  vulva  which 
he  collected  from  the  literature  and  found  that  more  occurred  between 
60  and  70  years  than  in  any  other  decade.  Winckel  found  the  greatest 
frequency  in  the  sixth  decade.  This  agrees  with  the  findings  of  Kehrer, 
Eberhart,  West,  Dittrick,  Winckelmann,  and  Frankl.  A  smaller  group 
have  found  the  greatest  frequency  in  the  fifth  decade.  Dittrick  states 
that  84  per  cent  of  the  cases  which  he  collected  from  the  literature  were 
more  than  45  years  of  age.  The  cancer,  however,  does  occur  at  an 
earlier  period,  and  has  been  noted  in  childhood.  Krysiewicz  noted  a 
case  at  4  years.  St.  Germain,  Launois,  le  Fileux,  each  described  cases 
at  5  years,  although  there  is  some  dispute  in  all  4  cases  as  to  whether 
the  tumor  was  sarcoma  or  carcinoma.  Kinoshita  recorded  a  case  14 
years  old;  Mertz,  16  years;  Lambert,  and  Fritsch,  each  a  case  18  years, 
Albert,  20  years;  Engstrom,  21  years;  Berecz,  23  years;  Townsend,  24 
years;  Perruchet,  and  Lutzenberger,  each  a  case  25  years. 

Etiology. — The  etiology  is  not  known.  Various  factors  have  been 
adduced  as  predisposing  causes.  Rothschild  voices  the  feeling  of 
nearly  all  students  of  the  question  when  stating  that  labor,  or  operative 
trauma  associated  with  labor,  does  not  seem  to  be  an  etiologic  factor. 
This  is  substantiated  by  the  fact  that  the  disease  often  occurs  in  nulli- 
para  or  virgins.  Lutzenberger  found  that  1 1  of  106  vulvar  cancers 
occurred  in  nullipara  or  virgins.  However,  Aschenborn  reported  one 
case  in  which  the  tumor  seemed  to  begin  shortly  after  confinement  and 
another  case  occurring  in  a  woman  who  had  had  eleven  forceps  deliv- 
eries. 

Nearly  all  admit  that  trauma  may  be  of  very  great  importance  as  a 
predisposing  factor.  West,  Ingerman  and  Amitin,  Aschenborn,  and 
Taussig  have  reported  cases,  the  development  of  which  seemed  closely 
related  to  a  fall  in  which  the  vulva  was  bruised.  Many  others  have 
reported  cases  which  developed  in  the  site  of  a  wound  which  remained 
unhealed  for  a  long  time. 


22  PELVIC   NEOPLASMS 

Pruritus  appears  to  be  most  important  as  a  predisposing  factor,  and 
many  men  have  emphasized  the  fact.  Pruritus  is  a  symptom  which 
may  be  the  result  of  many  conditions,  such  as  senile  changes  of  the 
labia  and  vagina,  irritation  from  leukorrhea,  the  urine  of  diabetes, 
uncleanliness,  masturbation,  etc.  Tasty,  and  also  Sassy,  go  so  far  as  to 
claim  that  pruritus  is  the  sole  predisposing  cause.  Some,  as  Basset, 
while  recognizing  that  pruritus  is  a  constant  initial  symptom,  differen- 
tiate between  the  various  conditions  which  are  responsible  for  it. 

A  voluminous  literature  also  emphasizes  the  association  between 
leukoplakia  and  kraurosis  as  forerunners  of  vulvar  carcinoma.  The 
importance  of  leukoplakia  as  a  forerunner  of  cancer  was  emphasized 
by  Reclus  and  Besc  in  1887.  Becker,  Bochinski,  Brettauer,  Jacobs, 
Yaile  and  Bender,  Martin,  Schwarz,  Teuffel,  and  a  number  of  others 
have  described  cases  of  vulvar  carcinoma  which  developed  in  kraurotic 
labia.  Yaile  and  Bender  describe  14  cases  and  Butlin  3  cases  in  which 
the  disease  arose  in  leukoplakic  patches.  All,  however,  do  not  agree. 
Frankl  states  that,  in  the  many  cases  which  he  saw  in  the  Schauta 
clinic,  there  was  only  i  during  six  years  in  which  there  was  present 
leukoplakia  and  carcinoma. 

Carcinomatous  degeneration  of  benign  tumors  of  the  vulva  have 
been  described  by  Cohnheim  and  a  long  list  of  others.  Benign  tumors 
of  the  vulva  are  not  uncommonly  noted.  Cohnheim  thought  that  the 
little  papilloma  often  preceded  the  malignant  tumor.  The  disease  fol- 
lowed luetic  ulcers  in  the  cases  of  Arnot  and  Hutchinson.  Maurel 
described  a  case  following  psoriasis.  Taussig,  who  saw  2  cases  in 
young  women  having  artificial  surgical  menopause,  re-advanced  the 
older  suggestion  that  ovarian  secretion  may  inhibit  the  development 
of  the  tumor,  especially  since  80  per  cent  of  vulvar  carcinoma  occur  in 
women  past  the  menopause. 

Appearance  and  Structure  of  Growth. — The  tumor  may  arise  from 
the  squamous  epithelium  of  the  labia  minora  or  majora  (carcinoma  of 
the  clitoris  is  included  in  a  separate  chapter).  In  the  beginning,  the  growth 
appears  either  as  a  small,  warty  tumor  or  as  a  localized  thickening  or 
ulcer  (Fig.  n).  At  the  site  of  the  lesion,  the  skin  is  excoriated  and  pig- 
mented  as  a  result  of  scratching.  At  first,  the  discrete  nodule  or  plaque 
is  freely  movable  over  the  underlying  tissue.  Ulceration  usually  occurs 
early  (average  of  six  months)  and,  shortly  following,  the  growth 
becomes  fixed  to  the  deeper  tissues.  The  tumor  then  begins  to  grow 
rapidly  and  may  assume  either  a  vegetating  fungoid  type  or  the  infil- 
trating form  (Maurel).  On  section,  the  tumor  appears  as  a  white, 
pearly  mass  in  which  are  yellow  spots  of  necrosis.  With  the  growth  of 
the  tumor,  the  epithelial  cords  dip  down  into  the  underlying  tissues  and 
gradually  involve  them.  Finally,  the  bones  are  invaded.  The  infil- 
trated form  does  not  elevate  the  overlying  skin.  It  ulcerates  early  and 
infiltrates  the  surrounding  structures.  The  edges  of  the  early  ulcer 


MALIGNANT  TUMORS  OF  OUTLET  23 

are  elevated  and  undetermined.     Later,  the  typical  craterlike  form  is 
seen. 

Classification. — Histologically,  the  growth  has  been  divided  into 
four  types:  (a)  scirrhus;  (&)  medullary,  depending  upon  the  amount  of 
connective  tissues;  (c)  cancroid,  characterized  by  numerous  epithelial 


FIG.   10. — SYPHYLOMA  OF  VULVA  RESEMBLING  CARCINOMA. 


pearls;  and  (d)  melanocarcinoma,  presenting  numerous  brown  or  black 
pigment  granules,  in  or  between  the  carcinoma  cells.  Several  observers 
agree  with  Rothschild  in  believing  that  the  tumors  of  this  latter  type, 
which  have  been  reported  for  the  most  part  in  earlier  literature,  were 
really  sarcomata. 


24  PELVIC   NEOPLASMS 

Method  of  Extension. — The  tumor  spreads  chiefly  by  the  lym- 
phatics to  the  neighboring  lymph  glands  which  it  soon  involves.  More 
rarely,  it  grows  by  contact,  although  there  are  many  cases  which 
illustrate  the  possibility.  The  growth  early  extends  into  the  lymph 
spaces  and  causes  degenerations  of  the  adjoining  tissues.  The  inguinal 
lymph  glands,  both  superficial  and  deep,  are  early  involved  and,  later, 
the  iliac,  sacral,  lumbar,  and  abdominal  glands  are  invaded.  The  pelvic 
glands  may  be  involved  secondarily  to  the  inguinal  nodes  or  primarily 
through  extensions  through  the  lymphatics  of  the  vagina.  The  inguinal 
glands  may  attain  such  large  size  as  to  interfere  with  the  blood  supply 
of  the  leg  and  cause  edema  and  even  gangrene.  Metastatic  nodules 
may  develop  in  tissues  on  the  opposite  side  of  the  labia.  The  disease 
may  become  widely  disseminated  and  may  involve  the  lung,  liver, 
heart,  spleen,  kidneys  (Kuestner,  Leger)  ;  pleura,  lungs,  heart, 
(Arnot)  ;  or  axillary  glands  and  breast  (Zeiss). 

Symptoms. — The  tumor  may  be  present  for  some  time  without 
causing  symptoms,  although  usually  pruritus  is  a  marked  complaint. 
This  symptom  may  come  on  in  paroxysms  and  may  cause  itching, 
burning,  or  pricking  sensations.  It  is  often  present  in  the  stage  in 
which  the  tumor  is  not  defined  and  when  a  definite  diagnosis  cannot 
be  made.  The  importance  of  this  symptom  in  women  at  or  beyond 
the  menopause  cannot  be  too  strongly  emphasized.  Patients  present- 
ing this  complaint  should  be  examined  carefully  and  frequently  because 
so  few  vulvar  cancers  are  really  cured. 

Pain  is  usually  a  late  symptom  and  comes  on  with  the  ulceration. 
Later,  there  is  a  discharge  of  a  whitish,  mucoid  character  which  soon 
becomes  bloodstained.  Hemorrhage  is  usually  a  terminal  event. 
Urinary  symptoms  of  burning,  scalding,  or  incontinence,  result  when 
the  urethra  has  become  involved  by  either  primary  or  secondary  exten- 
sion. Death  may  result  from  cachexia,  chronic  sepsis,  infection  of  the 
urinary  tract,  or  emboli. 

Diagnosis. — The  diagnosis  is  usually  easy  from  the  signs  previously 
described.  The  condition  must  be  differentiated  from  lupus,  sarcoma, 
and  luetic  ulcers.  The  former  usually  comes  on  in  younger  women,  leads 
to  dense  scar  formation,  and  tends  to  heal  under  treatment.  Sarcoma 
is  very  rare  and  can  be  differentiated  only  by  microscopic  study. 
Syphiloma  may  cause  some  difficulty  but  the  history,  Wassermann  reaction, 
and  the  therapeutic  tests,  should  establish  the  diagnosis  (Fig.  10). 

Prognosis. — The  prognosis  is  extremely  grave.  Death  invariably 
results  unless  the  entire  tumor  is  removed.  The  duration  of  the  dis- 
ease varies  considerably,  from  a  few  months  to  several  years,  although 
there  are  no  cases  reported  in  the  literature  in  which  the  course  of  the 
disease  was  not  influenced  by  some  type  of  treatment  (often  one  which 
aggravated  the  condition). 


MALIGNANT  TUMORS  OF  OUTLET  25 

Treatment. — The  treatment  of  carcinoma  of  the  vulva,  clitoris,  and 
Bartholin  glands  is  identical  with  that  of  any  malignant  condition  in 
this  area.  At  present,  the  only  hope  of  cure  is  a  surgical  removal  of  the 
entire  growth  by  a  wide  dissection,  not  only  of  the  local  parts  but  of 
the  lymphatics  which  drain  the  area.  Operation  is  extremely  difficult 
because  of  the  anatomy  of  the  lymphatic  channels.  The  vulvar  tissues 
are  well  supplied  with  lymph  tracts  which  drain  in  different  areas.  The 
prepuce  and  labia  drain  into  the  inguinal  glands.  The  glans  clitoris 


FIG.  ii. — CARCINOMA  OF  RIGHT  LABIUM  MINORA  IN  WOMAN  OF  SEVENTY. 


empty  chiefly  into  the  crural  and  inguinal  glands  which  anastomose 
with  the  pelvic  nodes.     Cross  drainage  to  the  other  side  is  present. 

Theoretically,  the  operation  should  include  in  one  piece  the  removal 
of  the  entire  labia  and  clitoris,  together  with  the  external  inguinal 
glands  and  the  structures  which  lie  between  the  glands  and  the  tumor 
(Fig.  12).  More  should  not  be  attempted,  since,  if  the  disease  has 
invaded  the  pelvic  glands,  the  condition  cannot  be  cured  by  any  pro- 
cedure now  known.  The  literature  contains  descriptions  of  many  more 
extensive  methods  which  have  been  tried,  unsuccessfully  for  the  most 


26 


PELVIC   NEOPLASMS 


part,  upon  women  in  whom  there  was  widespread  local  involvement 
and  apparent  invasion  of  the  glands.  The  same  rules  should  govern 
the  treatment  of  malignant  tumors  of  the  vulva  as  have  been  developed 
for  cervical  cancer,  that  is,  to  treat  by  surgery  only  the  cases  in  which 
there  is  every  reason  to  believe  that  operation  will  cure. 

The  fact  that  many  have  claimed  that  there  is  no  improvement  in 
the  operative  result  from  removal  of  the  glands  indicates  probably  that 
their  cases  were  extremely  late.  On  the  contrary,  Hoffman  reports 
a  case  in  which  recurrence  was  noted  after  a  radical  operation  only 
after  eight  years.  This  was  operated  again,  and  two  years  later 


FIG.  12. — AREA  OF  REMOVAL  FOR  CARCINOMA  OF  VULVA. 


another  recurrence  developed,  also  operated,  a  third  recurrence  two 
years  later,  and  again  after  three  years,  and  a  final  recurrence  after 
two  years.  All  these  recurrences  were  operated,  the  woman  living  at 
least  seventeen  years.  Lewers  operated  four  times  in  five  years  on 
another  vulvar  cancer.  The  first  operation  removed  the  tumor  and 
the  right-sided  inguinal  glands:  the  second  time  for  a  local  recurrence; 
the  third  time  because  the  incision  had  not  healed,  at  which  time  he 
removed  the  left  inguinal  glands;  the  fourth  time  there  was  a  local 
recurrence.  Five  years  after  the  last  operation,  there  was  no  sign  of 
recurrence  and  the  woman  was  free  from  pain.  Both  of  these  cases 
presented  fairly  early  growths. 


MALIGNANT  TUMORS  OF  OUTLET  27 

There  is  some  discussion  as  to  whether  the  operation  should  be 
performed  with  the  thermal  cautery  or  the  knife.  Both  methods  have 
their  advocates.  All  agree  that,  if  the  knife  is  .used,  great  precautions 
are  necessary  to  prevent  wound  implantation.  The  tumor  should  be 
surrounded  with  gauze  and  touched  only  with  forceps.  The  undeniable 
advantage  of  operation  with  the  knife  is  union  per  primum. 

Stoeckel,  McCann,  Mauclair,  and  Basset  have  described  operative 
procedures  which  permit  the  removal  of  the  entire  mass  in  one  piece. 
The  tumor  is  removed  from  above  in  all  cases. 

Stoeckel  makes  an  incision  on  the  abdomen  at  the  outer  border  of 
the  rectus  muscle  down  and  along  Poupart's  ligament  over  the  mons 
veneris  and  up  and  out  in  the  same  manner  on  the  opposite  side.  This 
incision  would  permit  an  extraperitoneal  removal  of  the  iliac  glands 
were  such  a  procedure  contemplated.  After  the  inguinal  glands  are 
removed  on  each  side,  the  tumor  is  dissected,  together  with  the  labia, 
working  down  from  above. 

McCann  made  an  incision  parallel  to  Poupart's  ligament  on  each 
side,  beginning  at  the  iliac  spines.  The  inguinal  and  crural  glands  are 
removed  with  the  surrounding  fatty  tissue,  together  with  the  tumor. 
He  also  attempted  the  extraperitoneal  removal  of  the  iliac  glands. 

Mauclair  ligated  the  external  iliac  artery  and  removed  in  succession 
the  crural  glands,  those  of  the  femoral  canal,  the  inguinal  and  finally 
the  iliac  glands,  after  which  the  tumor  was  excised.  This  operation 
has  few  advocates. 

Basset  developed  a  procedure  on  the  cadaver  which  permitted 
extensive  removals  by  a  fairly  conservative  procedure.  The  skin 
incision  runs  from  opposite  the  anterior  superior  iliac  spine,  downward 
and  inward  to  the  femoral  canal  and  then,  from  the  same  point,  down- 
ward and  inward  to  the  external  inguinal  ring,  stopping  at  the  level  of 
the  pubic  tubercle. 

The  fascia  of  the  external  oblique  is  cleansed  and  split  parallel  to  the 
inguinal  canal  in  its  whole  length.  The  round  ligament  appears.  The 
internal  oblique  and  transversalis  fascia  are  separated  from  Poupart's 
ligament  which  bares  the  entire  •length  of  the  round  ligament.  By 
retracting  upward,  keeping  outside  of  the  round  ligament,  the  lateral 
retrocrural  glands  appear  and  are  removed.  They  lie  in  the  region  of 
the  origin  of  the  deep  circumflex  iliac  artery. 

He  then  divides  Poupart's  ligament  just  inside  the  femoral  vein, 
ligates  and  divides  the  inferior  epigastric  vessels  which  gives  exposure 
of  the  median  retrocrural  glands.  Cloquet's  gland  lies  near  the  femoral 
veins  in  the  pectineal  fascia.  It  is  removed.  By  downward  retraction, 
the  cellular  and  fatty  tissues  are  now  removed  from  the  margins  of 
Scarpa's  triangle  down  to  the  labia  majora.  The  deep  femoral  glands 
lie  along  the  femoral  vein. 

He   advises   closure   of   the   first   incisions   before   attempting  the 


28  PELVIC  NEOPLASMS 

removal  of  the  tumor.  The  edges  of  Poupart's  ligament  and  the  pec- 
tineal  aponeurosis  are  united  to  the  ligament  corpori,  without  compro- 
mising the  femoral  vein.  The  muscles  are  then  united  to  the  recon- 
structed Poupart's  ligament  just  as  in  a  hernia.  The  tumor  is  then 
removed. 

Roentgen  rays  have  been  tried  by  many  surgeons  without  good 
results.  They  have  not  seemed  to  be  of  much  value  as  a  post-operative 
procedure. 

Radium  has  been  used  often  in  comparatively  recent  times.  We 
have  tried  it  in  several  cases  without  good  results,  yet  all  the  cases 
were  late  and  presented  well-developed  inguinal  tumors.  Bumm,  in 
1913,  treated  one  operable  vulvar  carcinoma  with  radium  and  reports 
a  five-year  cure.  In  1914,  he  treated  7  operable  cases  with  four-year 
cures  in  three.  In  1915,  he  treated  five  operable  tumors  with  recur- 
rence following  in  all  cases  three  years  later. 

Results. — The  results  are  not  good.  Dittrick  reviewed  the  liter- 
ature without  finding  a  single  case  which  he  felt  should  be  considered 
as  a  five-year  cure.  Goldschmidt  tabulated  214  cases  studied  from  a 
period  from  five  to  eight  years  and  found  8  cases  which  did  not  give 
evidence  of  recurrence.  Kuestner,  Zweifel,  Griinbaum,  Teller,  and 
Keeling  report  cases  which  recurred  after  eight  to  twelve  years. 
Rothschild  found  that  51  of  his  225  collected  cases  had  been  lost  for 
the  purposes  of  study.  Death  resulted  from  intercurrent  affections  or 
from  a  cause  not  stated  in  10  cases.  Of  the  164  cases  which  remained, 
recurrence  was  observed  in  142,  or  82  per  cent.  Recurrence  presented 
in  47  per  cent  of  these  during  the  first  year.  Many  of  these  cases  (34) 
had  the  glandular  returns  removed  shortly  after  their  appearance.  Of 
the  total  number,  4.87  per  cent  were  free  from  recurrence  at  the  end  of 
five  years.  The  disease  returned  in  8  of  the  164  cases  in  periods  of 
from  five  to  ten  years.  Recurrence  was  observed  in  the  glands  three 
times  more  frequently  than  in  the  region  of  the  primary  tumor. 

CARCINOMA  OF.THE  CLITORIS 

At  first  glance,  it  does  not  appear  that  carcinoma  of  the  clitoris 
deserves  consideration  apart  from  that  of  the  vulva.  The  clitoris  merely 
forms  part  of  the  vulva.  Its  tumors  present  problems  identical  with 
those  of  the  vulva  in  general.  Yet  we  know  so  little  of  cancers  in 
general  that  we  should  not  fail  to  take  advantage  of  every  bit  of  work 
that  has  been  done  in  a  careful  and  critical  manner. 

Since  the  first  case  of  carcinoma  of  the  clitoris  was  reported  by 
Hutchinson  in  1850,  theer  has  accumulated  a  considerable  literature. 
Douriac,  in  1888,  made  the  first  extensive  review  and  collected  22  cases, 
Bjorkvist,  in  1903,  cited  65  cases.  Jacoby,  in  1904,  tabulated  67. 
Basset,  in  1912,  collected  147  and  worked  out  details  of  treatment.  By 


MALIGNANT  TUMORS  OF  OUTLET  29 

1919,  the  number  of  reported  cases  had  grown  to  such  an  extent  that 
Ederle  was  able  to  collect  183  which  formed  the  basis  for  his  critical 
review. 

Type  of  Growth. — Epithelioma  arising  from  the  squamous  cell 
epithelium  is  the  usual  type.  A  few  adenocarcinoma  have  been  de- 
scribed. The  tumors  may  be  primary,  or  secondary  from  carcinoma 
in  adjoining  parts  of  the  labia. 

Frequency. — Various  attempts  have  been  made  to  show  the  fre- 
quency. In  the  cases  of  Gurlt,  Schultze,  Engstrom,  Teller,  A.  Frank!, 
Lutzenberger,  Ossing,  and  Rothschild,  there  were  677  vulvar  carci- 
noma, 109  of  which  were  in  the  clitoris  (16  per  cent). 

Etiology. — The  etiology  is  not  known.  Nearly  every  possible 
theory  has  been  advanced,  but  none  seems  applicable  to  any  consider- 
able number  of  cases. 

A  small  number  of  instances  in  which  the  disease  occurred  in  the 
young  may  be  explained  possibly  by  the  Cohnheim  theory.  Some  form 
of  chronic  irritation  has  been  urged  as  the  causal  factor  of  the  larger 
group  of  cases,  yet  the  relation  is  rarely  conclusive. 

The  idea  that  excessive  sexual  activity  or  masturbation,  etc.,  may 
have  much  to  do  with  causing  the  disease  seems  disproved  by  the  fact 
that  very  few  of  the  cases  occurred  in  prostitutes,  and  on  the  contrary 
a  very  appreciable  percentage  were  observed  in  virgins.  Rather  closely 
related  is  the  theory  that  the  growth  is  likely  to  follow  chronic  inflam- 
matory processes,  and  especially  those  which  led  to  pruritus.  Cumston 
and  Hutchinson  thought  that  syphilis  was  a  factor.  The  same  objec- 
tions apply  to  both.  Pruritus  and  syphilis  unfortunately  are  very  com- 
mon, whereas  carcinoma  of  the  clitoris  is  extremely  rare. 

More  tangible  is  the  view  that  there  is  a  definite  relationship 
between  leukoplakia,  kraurosis  and  carcinoma  of  the  clitoris.  This  is 
confirmed  by  the  findings,  yet  there  is  a  tremendous  percentage  of 
these  cancers  that  have  never  had  either  leukoplakia  or  kraurosis.  The 
association  of  leukoplakia  and  carcinoma  of  the  clitoris  is  proved  by 
7  cases.  Six  cases  developed  in  kraurotic  areas,  and  2  cases  in  the 
literature  had  had  both  leukoplakia  and  kraurosis. 

Many  have  called  attention  to  the  fact  that  benign  tumors  are 
more  likely  to  undergo  carcinomatous  changes  in  some  areas  than  in 
others.  We  have  already  noted  the  high  proportion  of  sarcomatous 
changes  in  vulvar  fibroids.  Nonmalignant  tumors  of  the  clitoris  are 
not  common,  yet  there  are  8  cases  in  the  literature  in  which  benign 
tumors,  such  as  papilloma,  fibroma,  angioma  and  cysts  of  the  clitoris, 
were  followed  by  carcinoma. 

It  is  more  difficult  to  establish  a  relation  between  actual  trauma 
and  carcinoma  of  the  clitoris.  There  are,  however,  three  cases  in  which 
the  disease  followed  trauma  not  associated  with  childbirth.  One  of 
these  was  injured  while  sliding  on  an  icy  hillside  and  another  in  a  fall. 


30  PELVIC   NEOPLASMS 

Attempts  to  associate  the  disease  with  lacerations  of  the  clitoris 
during  childbirth  or  from  forceps  injuries  have  failed. 

Parity. — While  the  disease  is  practically  one  of  women  who  have 
borne  children,  it  has  occurred  in  a  considerable  number  of  nullipara 
and  a  definite  percentage  of  virgins. 

The  parity  in  66  cases  is  given  as  follows : 

o-  i   para 19  cases 

2-  4  para 16  cases 

5-  7  para 12  cases 

8-10  para 14  cases 

1 1-13  para 5  cases 

Menopause. — The  older  authors  believed  that  the  disease  was  more 
common  about  the  menopause.  This  view  no  longer  holds. 

Age. — The  age  incidence  is  practically  that  of  vulvar  carcinoma, 
though  there  is  a  larger  proportion  of  cases  in  the  young.  There  is 
a  rapid  increase  in  the  number  of  cases  after  the  age  of  40.  The 
greatest  incidence  is  in  the  seventh  decade  as  shown  by  Ederle. 

EDERLE'S  TABLE 


Years 

Cases 

Per  Cent 

20-30 

7 

4-4 

30-40 

ii 

6.9 

40-50 

23 

14-5 

50-60 

40 

25-1 

60-70 

61 

38.4 

70-80 

15 

9-4 

80-90 

2 

i-3 

Location. — In  the  majority  of  cases,  the  tumor  is  situated  in  the 
folds  of  the  nymphse,  between  the  large  and  small  labia;  more  seldom  in 
the  glans ;  least  often  in  the  prepuce  of  the  clitoris. 

Gross  appearance  and  form. — Three  types  of  primary  tumors  have 
been  described:  (i)  a  more  or  less  circumscribed  growth  (Fig.  13); 
(2)  one  presenting  as  a  diffuse  infiltration;  and  (3)  a  form  suggesting 
Paget's  disease,  in  which  the  growth  does  not  give  the  usual  picture 
of  malignancy. 

(i)  The  growth  is  more  or  less  circumscribed.  Under  this  heading 
are  three  subtypes : 

(a)   One  in  which  there  is  an  ulcerated  tumor  sharply  demarcated 

from  the  surrounding  tissue. 

(6)   A  papillomatous  tumor  frequently  with  a  definite  pedicle. 
(c)   Enlargement  of  the  clitoris  yet  preserving  more  or  less  of  its 
normal  outlines. 


MALIGNANT  TUMORS  OF  OUTLET 


(2)   The  growth  presents  as  a  diffuse  infiltration  which  is  firmly  fixed 
to  the  deeper  tissues.     Occasionally  the  skin  surmounting  the  growth  is 


P!G.  I3. — CARCINOMA  CLITORIS  WITH  AREA  OF  IMPLANTATION  BY  CONTACT  ON  THE 
LEFT  LABIUM  MAJUS  (Kelly,  Operative  Gynecology). 

elevated  en  masse.     It  may,  however,  show  only  small  islands  of  elevation. 

(3)   A  form  somewhat  resembling  Pager's  disease.     The   skin  in 

this  type  is  soft,  but  contains  scattered  through  it  at  intervals  a  num- 


32  PELVIC  NEOPLASMS 

her  of  small  pea-  to  bean-sized  nodules.  At  the  edge  of  the  neoplasm 
is  a  fine,  white,  slightly  raised  epithelial  border.  This  type  at  first  sight 
does  not  suggest  a  cancer.  The  diagnosis  usually  is  made  only  with 
the  microscope. 

Cancers  of  the  clitoris  which  develop  secondary  to  carcinoma  else- 
where are  frequently  described.  Most  of  these  are  direct  extensions 
from  carcinoma  of  the  labia.  Yet  there  are  a  number  of  cases  recorded 
in  which  the  clitoris  was  finally  involved  by  direct  extensions  from  car- 
cinoma of  the  uterus,  which  sent  off  offshoots  through  the  vagina 
until  finally  they  reached  the  clitoris.  The  clitoris  may  also  be  the 
seat  of  metastases  from  cancer  of  the  uterus,  and  7  cases  of  this  com- 
plication have  been  described.  Weibel  reports  a  case  in  which  the 
metastasis  appeared  subsequent  to  the  operative  removal  of  the  uterus. 
Some  men  have  tried  to  prove  that  carcinoma  of  the  ovary  has  given 
rise  to  metastases  in  the  clitoris.  Such  cases,  however,  are  difficult  to 
establish. 

Histology. — There  are  two  types  of  squamous  cell  carcinoma  of 
the  clitoris;  the  infiltrating,  cornifying  epithelioma,  and  the  flat,  ulcer- 
ating, basal  cell  type.  The  former  is  more  common. 

Adenocarcinoma  have  also  been  described  (Bertino),  arising  as 
primary  growths  from  the  epithelium  of  'the  sebaceous  or  sweat  glands 
of  the  prepuce  of  the  clitoris,  or  a  seco-hdary  metastasis  from  other 
adenocarcinoma  of  the  pelvis. 

Symptoms. — Itching,  as  in  other  carcinoma  of  the  vulva,  is  usually 
the  first  symptom.  After  a  longer  or  shorter  period,  sticking  pains 
appear  first  in  the  vulva,  then  in  the  inguinal  regions  and  later  in  the 
extremities.  With  the  advent  of  ulceration,  there  is  a  serosanguineous 
discharge  which  soon  becomes  foul,  and  which  may  lead  to  excoriations 
of  the  thigh  which  do  not  heal  readily.  Bleeding  is  a  late  symptom  and 
usually  is  present  only  when  the  growth  is  sloughing.  This  seems 
rather  remarkable,  because  the  clitoris  is  such  a  vascular  organ.  Dys- 
pareunia  is  common.  Urinary  symptoms  are  usually  present.  At  first 
merely  tenesmus,  there  may  follow  obstruction  to  the  flow  when  the 
meatus  becomes  involved.  Later  there  is  incontinence.  Walking  is 
painful,  especially  in  the  later  stages  because  of  the  excoriations  on 
the  thighs  and  the  ulceration  of  the  labia.  Pressure  symptoms  may 
result  when  the  inguinal  glands  attain  size  sufficient  to  exert  pressure 
on  the  nerves  or  to  cause  mechanical  interference  with  the  circulation. 

Treatment. — The  treatment  is  similar  to  that  of  vulvar  carcinoma 
(q.  v.). 

CARCINOMA    OF   BARTHOLIN    GLANDS 

Carcinoma  developing  primarily  in  Bartholin  glands  has  very  rarely 
been  described.  The  largest  series  of  which  we  find  record  is  Spencer's, 


MALIGNANT  TUMORS  OF  OUTLET  33 

who,  in  1913,  in  London  collected  18  cases.  There  are  a  number  of 
other  cases  scattered  through  the  literature,  but  the  list  is  not  large. 
Until  1915,  there  were  only  15  cases  in  the  German  literature.  In  this 
country,  Kelly  reports  a  single  case,  as  has  Peterson,  and  a  few  others. 
We  have  met  with  only  i  case  in  a  fairly  large  series  of  pelvic  cancers. 
Quite  possibly  the  condition  occurs  more  commonly  than  is  indicated 
by  the  literature,  since  in  vulvar  carcinomata  which  come  late  for  treat- 
ment it  is  often  quite  impossible  to  ascertain  the  point  of  origin  of  the 
growths. 

Classification. — The  chief  interest  attached  to  cancers  of  the  Barth- 
olin  glands,  other  than  those  of  the  vulva  in  general,  lies  in  the  fact 
that  both  squamous  cell  carcinoma  and  adenocarcinoma  have  been 
proved  to  develop  in  the  Bartholin  glands.  Since  this  at  first  sight 
seems  incredible,  it  is  worthy  of  consideration.  Both  types  occur  with 
equal  frequency. 

The  acini  of  Bartholin  glands  are  lined  with  columnar  epithelium. 
Consequently  a  cancer  developing  in  this  lining  will  be  an  adenocar- 
cinoma. Observers  are  not  agreed,  however,  as  to  the  character  of 
the  cells  lining  the  gland  ducts,  other  than  that  they  are  of  the  tran- 
sitional type.  The  chief  ducts  usually  show  a  layer,  two,  three  or  four 
cells  deep  in  the  mid-portions.  Near  the  point  at  which  it  opens  on 
the  vulvar  skin,  the  lining  passes  over  to  the  skin  type  of  squamous 
epithelium.  Occasionally,  however,  the  entire  length  of  the  ducts  is 
covered  by  squamous  cell  epithelium.  Whether  this  be,  as  some  claim, 
the  result  of  an  inflammatory  metaplasia  whereby  the  columnar  or 
transitional  epithelium  is  replaced  by  a  well-developed  layer  of  the 
squamous  cell  epithelium,  as  is  frequently  noted  in  small  areas  in  the 
cervix  and  uterine  cavity  is  as  yet  an  open  question.  This  view  is 
championed  by  K.  Teuton,  G.  Nobels,  and  by  Sitzenfrey,  all  of  whom 
have  described  ducts  lined  by  squamous  cell  epithelium  in  cases  with 
gonorrheal  Bartholinitis.  Cancers  developing  from  areas  in  the  duct 
lined  by  squamous  cell  epithelium,  naturally  will  be  squamous  cell 
epitheliomas.  This  type  of  cancer,  when  seen  in  advanced  growths, 
may  not  be  differentiated  from  the  more  common  vulvar  carcinoma. 

Etiology. — The  same  theories  which  are  advanced  for  carcinoma 
in  general  apply  to  cancer  in  Bartholin  glands.  Many  have  emphasized 
the  fact  that  the  great  majority  of  the  cancers  of  the  Bartholin  glands 
had  had  previous  gonorrheal  infections;  although  we  may  remark  in 
passing  that  were  gonorrheal  infection  of  Bartholin  glands  the  chief  etio- 
logical  factor,  there  would  be  millions  of  such  cancers  rather  than 
the  dozens  which  have  been  recorded.  Eden  quotes  a  case  of  a  woman 
who  had  an  abscess  on  the  left  labium  which  drained  for  one  and  a 
half  years,  when  a  lump  appeared  in  the  same  region  which  was  proved 
to  be  adenocarcinoma.  Kelly's  case  appears  to  have  developed  on  an 
inflammatory  basis.  It  was  first  incised  under  the  impression  that  it 


34  PELVIC   NEOPLASMS 

was  an  abscess,  which  idea  was  confirmed  by  the  large  quantity  of 
cheesy,  bloodstained  debris  which  escaped  with  clots.  The  first  sug- 
gestion of  the  carcinomatous  nature  did  not  present  until  her  return 
four  months  later. 

Age. — The  carcinoma  usually  appears  after  the  menopause. 
Spencer  and  Wittkopf  each  have  reported  a  case  of  the  disease  in 
women  under  thirty,  both  of  whom  had  had  a  gonorrheal  infection  of 
the  gland.  Our  case  was  forty-eight  years. 


FIG.  14. — CARCINOMA  BARTHOLIN  GLAND  (Kelly,  Operative  Gynecology). 

Gross  appearance. — The  tumor  varies  in  size  from  a  small  pea-sized 
nodule  to  a  cauliflower  mass  even  larger  than  a  goose  egg  (Fig.  14). 
It  is  usually  firm  and  nodular  but  may  be  soft  and  suggest  an  abscess, 
probably  as  a  result  of  bacterial  invasion.  The  smaller  growths  are 
usually  red  (from  inflammatory  reaction),  but  have  been  described  as 
blue  with  large  skin  veins  surmounting  the  tumor.  Ulceration  usually 
occurs  early,  and  the  growth  presents  the  typical  appearance  of  a  car- 


MALIGNANT  TUMORS  OF  OUTLET  35 

cinomatous  ulcer,  with  its  punched-out  edges  and  a  necrotic  sloughing 
base.  The  edges  are  firm,  and  the  tumor  bleeds  readily.  With  the 
coming  of  ulceration,  the  surrounding  tissues  become  infiltrated,  and 
the  mass  becomes  firmly  attached  to  the  underlying  pubic  bones.  The 
glands  are  early  involved,  and  enlarge  not  only  from  carcinomatous 
invasion  but  especially  from  the  inflammatory  reaction.  Either  side  is 
attacked  with  equal  frequency.  The  growth  may  be  primary  in  both 
sides,  or,  as  shown  by  the  case  of  Schluter,  both  sides  may  be  involved 
secondarily  from  extensions  from  a  cancer  of  the  uterine  body. 

Symptoms. — Subjective  symptoms  may  be  absent  when  the  growth 
is  small,  especially  if  the  skin  is  intact.  Occasionally  there  is  dull  pain. 
With  the  advent  of  ulceration,  the  pain  may  be  acute,  lancinating  in 
character,  and  worse  when  walking,  or  during  menstruation.  Purulent 
leukorrhea  may  be  present,  usually  attributed  to  a  discharging  abscess. 
Hemorrhage  following  trauma  may  first  draw  the  patient's  attention 
to  the  growth,  as  in  the  case  of  Wittkopf. 

Diagnosis. — The  diagnosis  of  malignancy  is  usually  easy  but  may 
be  most  difficult  as  in  the  case  of  Kelly.  The  fixed  growth,  ulceration, 
involvement  of  glands  are  typical  when  present.  It  may  be  difficult 
to  differentiate  late  growths  from  cancers  of  other  structures.  Gott- 
schalk,  Eberth,  Koppe  and  others  have  emphasized  the  fact  that  there 
are  other  adenoid  elements  than  the  Bartholin  glands  in  the  pelvis, 
due  probably  to  misplacements  of  epithelial  elements  in  early  em- 
bryonic life  from  which  adenocarcinoma  may  arise.  The  location  of 
the  tumor  and  its  low-power  microscopic  picture  will  usually  give  the 
diagnosis  in  the  early  cases  of  adenocarcinoma,  since  the  growth 
tends  to  simulate  atypically  the  outlines  of  the  original  gland.  The 
diagnosis  may  not  be  made  in  the  squamous  cell  carcinoma  which 
originates  in  the  ducts  unless  the  surrounding  skin  is  free  from  car- 
cinoma. This  usually  is  easily  demonstrated  in  the  early  cases. 

Prognosis. — The  prognosis  is  most  gloomy,  irrespective  of  treat- 
ment. It  is  usually  said  that  no  case  in  literature  has  survived  the 
five-year  period  without  evidence  of  local  or  glandular  recurrence.  Yet 
any  one  who  turns  to  the  literature  will  be  amazed  at  the  paucity  of 
follow-up  notes.  Several  record  their  cases  as  clinically  cured  after 
one  or  two  years.  It  is  high  time  that  all  recognize  that  five  years  of 
freedom  from  recurrence  is  the  minimum  that  may  be  counted  as  cure. 

Metastasis  is  primarily  to  the  external  inguinal  glands.  There  is 
a  cross  system  whereby  glands  of  the  groin  of  the  opposite  side  may 
be  involved.  At  the  same  time,  the  growth  drains  to  the  pelvis,  and 
the  iliac  glands  are  often  involved.  The  pelvic  bones  are  early  affected 
and  metastasis  may  be  widespread. 

Treatment. — The  treatment  is  that  of  other  vulvar  cancers  (q.  v.). 


36  PELVIC  NEOPLASMS 


SARCOMA  OF  THE  VULVA 

Primary  sarcoma  of  the  vulva  is  an  exceedingly  rare  condition  and 
is  usually  briefly  discussed,  if  mentioned  at  all,  in  gynecological  text- 
books. Veit,  in  discussing  this  tumor,  states  that  it  is  so  rare  that  it 
is  difficult  to  establish  its  clinical  picture. 

In  contrast  to  the  primary  sarcoma,  there  have  been  described  a 
number  of  secondary  vulvar  sarcomata  which  have  resulted  from  the 
extension  of  growths  primary  in  the  vagina  or  pelvic  connective  tis- 
sues or  from  sarcomatous  changes  in  vulvar  fibroids  (q.  v.).  They  will 
not  be  considered  under  this  section.  The  following  deals  with  primary 
sarcomatous  growths  of  the  vulva. 

Classification. — Vulvar  sarcomata  may  be  pigmented  (melanosar- 
comata),  or  nonpigmented,  and  are  composed  of  round,  spindle  or 
mixed  cells.  Occasionally  a  melanotic  tumor  presents  a  cell  picture 
which  is  so  atypical  that  there  may  be  difficulty  in  determining  whether 
the  growth  is  sarcoma  or  carcinoma.  Such  tumor  usually  shows  an 
alveolar  structure.  Further  difficulty  has  arisen  in  the  classification 
of  a  small  group  of  tumors  which  usually  appear  first  without  color 
and  far  later,  and  occasionally  only  in  the  local  recurrence  after  opera- 
tion, exhibit  the  typical  deep,  blackish-brown  pigmentation  of  the  mela- 
nomata.  These  properly  belong  to  the  melanotic  division,  since  Rib- 
bert  has  shown  that  there  may  be  colorless  primary  melanosarcomata. 

Frequency. — The  rarity  of  this  disease  is  shown  by  many  authors. 
Eiselt  reviewed  104  melanomata  (both  sarcoma  and  carcinoma)  re- 
porting the  literature  from  1806  to  1861  without  finding  one  develop- 
ing in  the  external  genitalia.  Dieterich,  who  continued  Eiselt's  tabu- 
lation up  to  1887,  found  ii  vulvar  melanotic  sarcomata  in  the  review 
of  249  melanomata.  None  of  the  483  sarcomata  in  the  widely  quoted 
statistics  of  Gurlt  are  vulvar.  Caruso,  in  1889,  collected  28  vulvar 
sarcomata,  12  of  which  are  melanotic,  yet  Blair  Bell  in  reviewing  this 
series  of  reported  cases  reduced  the  list  considerably  by  exclusions 
warranted  by  the  study  of  the  various  individual  case  reports.  Torg- 
gler,  in  1900,  stated  that  there  were  52  primary  vulvar  sarcomata  re- 
ported in  the  literature  and  abstracted  the  histories  of  20  melanotic 
cases.  It  is  quite  possible  that  his  list  contains  many  doubtful  cases, 
since  Blair  Bell,  in  1907,  in  a  fairly  exhaustive  report,  was  able  to 
find  but  21  cases  of  primary  nonpigmented  vulvar  sarcomata.  P. 
Meyer,  in  1908,  cites  39  sarcomata  of  the  vulva,  although  it  appears 
to  us  that  he  includes  several  melanocarcinomata.  Veit,  in  1909,  states 
that  35  cases  of  nonpigmented  growths  have  been  reported  together 
with  the  same  number  of  pigmented  sarcomata.  Yet  we  find  in  this 
series  several  cases  which  at  least  appear  to  be  more  properly  sarco- 
matous changes  in  vulvar  fibroids  of  which,  there  are  now  many  re- 


MALIGNANT  TUMORS  OF  OUTLET  37 

ported  cases  in  the  literature.  In  1913,  Voigt  was  able  to  find  only  9 
cases  of  melanosarcomata  of  the  clitoris. 

Textbooks  usually  state — probably  quoting  from  Veit — that  the 
majority  of  vulvar  sarcomata  are  melanotic  but  we  cannot  find  on 
what  authority.  The  tabulations  of  Caruso  and  Torggler,  which  are 
the  largest  recorded,  show  respectively  12  melanotic  sarcomata  in  a 
series  of  28  vulvar  sarcomata,  and  20  melanomata  in  a  total  series  of 
52  vulvar  sarcomata. 

Etiology. — Little  is  actually  known  concerning  the  etiology, 
although  it  would  appear  as  if  nearly  every  possible  theory  had  been 
advanced  to  explain  the  origin.  Heredity  is  not  proved.  Some,  when 
considering  the  etiology  of  the  melanotic  sarcoma,  have  thought,  as 
Wagner,  that  possibly  blondes  were  more  likely  to  be  affected,  an  idea 
prompted  by  the  fact  that  in  horses,  the  white  horse  alone  appeared 
to  be  predisposed  to  melanotic  tumors.  The  literature  unfortunately 
does  not  permit  cf  chance  for  corroboration,  since  the  complexion  of 
the  patient  is  seldom  given,  although  several  cases  have  been  cited 
in  the  negro. 

Trauma  does  not  appear  to  be  an  important  predisposing  factor 
for  sarcoma  of  the  vulva,  since  the  vulva  has  been  developed  by  nature 
to  withstand  much  trauma.  This  point  appears  well  proved  when  we 
consider  the  inevitable  trauma  of  labor  and  the  fact  that  the  vulva 
is  especially  resistant  to  infections. 

Age. — In  marked  contrast  to  sarcoma  in  general  which  is  often  a 
disease  of  youth,  the  vaginal  sarcoma  usually  develops  in  later  life. 
The  age  incidence  in  18  nonpigmented  vulvar  sarcomata  collected  by 
Bell  is  as  follows  : 

• 

Under       10        years i  case 

Between   18-30      "     5  cases 

30-50      "    9      " 

50-70      "    3      " 

The  melanotic  tumors  are  noted  in  even  older  women.  Torggler's 
cases,  in  which  the  youngest  was  thirty-seven  years  and  the  oldest 
seventy-two,  present  the  following: 

Between       30-40  years i   case 

40-50       "      3  cases 

50-60       "      5      " 

60-70       "      4      " 

More  than  70  "      3 

Meyer's  series  of  30  melanomata  in  which  some  melanotic  carci- 
nomata  are  probably  included  gives: 


38  PELVIC   NEOPLASMS 

Between  20-30  years I   case 

30-40      "    2  cases 

40-50      "'    5      " 

50-60        "       12        " 

60-70      "     8      " 

70-80        " 2        " 

The  ages  were  given  in  6  of  Vogt's  9  cases  of  melanotic-sarcoma  of 
the  clitoris  as  37,  48,  51,  57,  and  70  years. 

Point  of  Origin. — The  tumor  may  develop  from  any  vulvar  tissue 
of  mesodermic  origin  or  from  the  periosteum  of  the  bones  which 
underly  the  external  genitalia. 

There  has  been  much  discussion  as  to  the  exact  point  of  origin  of 
the  melanotic  sarcomata.  Obviously  they  must  develop  from  cells 
containing  pigment.  There  are  a  great  number  of  possibilities, 
although  it  would  appear  that  they  may  develop  from  any  chromo- 
phore.  Unna  claimed  that  these  tumors  develop  from  pigmented  soft 
naevi.  Weiner  also  sought  their  origin  in  pigmented  moles  or  warts.  Diete- 
rich  in  this  connection  found  that  37  of  145  melanosarcomata  of  various 
parts  of  the  body  had  had  pigmented  naevi  as  a  possible  site  of  origin,  as 
did  Just  in  a  smaller  series  in  which  it  would  appear  that  23  of  54  mela- 
notic skin  tumors  also  developed  from  moles.  Von  Rave  collected  55  mela- 
nomata  which  developed  from  pigmented  warts  but  none  of  his  cases  were 
vulvar  growths.  On  the  other  hand,  Torggler  states  that  he  could  not  de- 
termine any  relationship  between  naevi  and  the  melanosarcomata  which  he 
reported  or  reviewed. 

There  is  no  doubt  but  that  there  are  many  pigmented  cells  in  the 
external  genitalia,  and  that  these  increase  in  number  during  pregnancy, 
or  as  the  result  of  certain  chronic  inflammations  as  intertrigo,  etc. 
Veit  saw  in  these  the  origin  of  the  melanotic  sarcoma.  There  are, 
however,  other  pigmented  areas  in  the  body  from  which  melanotic 
tumors  might  develop  but  do  not  appear  to  do  so.  Thus,  Torggler 
calls  attention  to  the  fact  that  no  melanotic  sarcoma  has  been  described 
which  originated  in  the  pigmented  areas  about  the  nipple  which  con- 
tains darker  cells  than  other  parts  of  the  skin  surfaces. 

Location  and  Appearance  of  Growth. — The  majority  of  the  vulvar 
sarcomata  develop  in  the  labia,  after  which  the  growths  in  the  clitoris 
and  urethra  follow  in  order  of  frequency.  Twelve  of  the  20  melanotic 
sarcomata  collected  by  Torggler  were  labial,  4  were  on  the  clitoris 
and  i  each  on  the  urethra',  mons  and  perineum.  Fourteen  of  Bell's 
series  of  21  nonpigmented  cases  were  labial,  with  3  each  on  the  urethra 
and  clitoris  and  i  on  the  vestibule.  The  exact  point  of  origin,  however, 
is  often  difficult  to  determine  with  accuracy  in  cases  which  come  late 
for  treatment.  Sanger  noted  a  case  in  the  hymen. 

In  appearance,  as  long  as  the  tumor  is  not  ulcerated,  it  may  re- 


MALIGNANT  TUMORS  OF  OUTLET 


39 


semble  either  the  vulvar  fibroma  or  lipoma.  It  is  round  or  oval  with 
the  long  axis  parallel  to  that  of  the  labia  and  often  contains  nodules. 
It  may  be  sharply  circumscribed.  Sometimes,  on  the  contrary,  it  has 
a  diffuse  border.  Occasionally  it  is  pedunculated ;  the  growths  of  the 


FIG.  15. — SARCOMA  CLITORIS  (redrawn  from  Simmons) 

clitoris  are  usually  so  (Fig.  15).  It  is  not  tender  and  is  firmly  fixed.  Ulcer- 
ation  to  the  deeper  structures  occurs  after  a  variable  interval,  and  the 
growth  becomes  fungated.  The  pigmented  forms  present  light  brown  to 
greenish  black  in  color.  The  surrounding  skin  is  unchanged  at  first 
and  may  move  freely  upon  the  growth.  Later  it  is  fixed  and  may  be 
edematous. 


40  PELVIC   NEOPLASMS 

The  tumor  usually  grows  with  astonishing  rapidity,  although  occa- 
sionally it  remains  latent  for  a  considerable  period. 

Metastasis. — Metastasis  usually  occurs  early  and  through  the 
lymphatics.  Later  the  cells  break  through  into  the  blood  stream  and 
involve  even  the  most  distant  organs.  None  appear  to  be  immune, 
and  metastases  in  the  liver,  stomach,  intestines,  ovary,  lung,  heart, 
brain  and  kidney  have  been  described.  The  neighboring  bones  may  be 
affected.  The  adjacent  lymph  glands  may  enlarge  to  tremendous  size, 
especially  in  the  melanotic  types.  Glandular  involvement  in  the  groin 
the  size  of  two  fists  is  not  uncommon.  The  chain  of  glands  nearest 
the  tumor  absorb  most  of  the  pigment  until  metastasis  is  fairly  general. 

Clinical  Picture. — Martin,  who,  in  1913,  reviewed  the  sarcoma  of 
the  labia  majora  reported  in  the  literature,  gives  the  following  picture: 

There  is  a  first  stage  which  may  last  for  years,  when  there  is  only  a 
small  indolent  nodule  or  a  more  or  less  pigmented  nsevus.  During  the 
second  stage,  there  is  a  more  or  less  rapid  growth  of  the  tumor,  which 
becomes  troublesome,  but  not  painful.  In  the  third  stage,  there  is  a 
tendency  to  spread  to  the  inguinal  glands,  to  the  labia  of  the  other 
side,  to  the  clitoris  and  muscles.  Presently  there  is  compression  of  the 
saphenous  and  femoral  vessels,  resulting  in  edema,  and  finally  in  meta- 
stasis and  death. 

Symptoms. — The  symptoms  are  similar  to  those  of  other  vulvar 
neoplasms,  namely,  itching,  burning,  dysuria,  and  a  sense  of  weight 
or  pressure  in  the  pelvis.  Discharge,  usually  foul,  may  be  present,  and 
bleeding  on  slight  touch  is  common.  Hemorrhage  may  be  very  pro- 
fuse and  be  the  cause  of  exitus.  In  melanotic  sarcoma,  the  mucous 
membranes  may  become  discolored  and  melanin  may  be  excreted  in 
the  urine,  especially  if  the  kidneys  are  involved  in  metastasis.  If  the 
pigment  is  excreted  as  melanin,  the  urine  is  dark.  Melanogen  causes 
but  little  darkening  of  the  urine.  On  standing,  however,  the  pigment 
is  oxidized  with  resulting  deepening  of  color.  A  melanemia  may  occur 
in  case  of  general  spread  of  melanotic  elements  in  the  body. 

Diagnosis. — The  diagnosis  can  be  made  only  with  the  microscope, 
although  there  is  usually  no  doubt  of  the  malignancy  of  the  well-developed 
tumor. 

Treatment. — The  treatment  is  wide  removal,  made  as  early  as  pos- 
sible, of  the  vulva  and  inguinal  lymphatics  in  one  piece  bv  a  careful 
and  wide  dissection — the  same  as  in  vulvar  carcinoma  (q.  v.).  X-ray 
has  not  given  results.  Radium  is  yet  untried  in  any  series  of  cases. 

Prognosis. — The  prognosis  is  grave.  Death  appears  to  result  uni- 
formly in  cases  in  which  the  diagnosis  of  vulvar  sarcoma  is  firmly 
established.  There  are  only  2  cases  in  the  literature  which  appear  in 
contrast  to  the  rule  that  death  follows  from  a  few  months  to  a  year 
following  diagnosis:  Fergusson's  case  of  a  pigmented  tumor  of  the 
mons  reported  in  1851  which  did  not  .present  recurrence  until  two 


MALIGNANT  TUMORS  OF  OUTLET  41 

years  after  removal;  and  Fischer's  case  of  perineal  tumor  with  masses 
in  the  inguinal  region  the  size  of  two  fists  which  remained  twenty  years 
before  recurrence  and  then  survived  a  second  operation  for  twelve 
years.  The  dates  of  these  reports,  1851  and  1881,  suggest  at  least  the 
chance  of  error  in  diagnosis. 

LITERATURE 

BELL.     Sarcoma  of  the  Vulva.     Journ.   Obs.  and  Gyn.   British  Empire. 

October,  1907. 
CARUSO.     Sarcoma  of  the  Vulva.     Soc.  it.  di.  ost.  e.  Gyn.     Vol.  2.     1896. 

Ref.  Zentr.  f.  Gyn.    1896.     p.  908. 
DIKTERICH.     Ein  Beitrag  zur  Melanotischen  Geschwiilste.  Archiv  f.  Klin. 

Chir.     1887.     35:289. 

EISELT.     Prager  Vierteljahrsschrift.     Bd.  59,  Bd.  70  and  Bd.  71. 
FERGUSSON.     Recurrence  of  melanotic  Tumor.    Lancet.     1851.     p.  622. 
FISCHER.     Ueber  Krebskrankheit.   Deutsche  Ztschr.   f.   Chirurgie.      1881. 

14:548. 

GEBHARD.     Path.  Anat.  Weiblicher  Sexual  Organen. 
GURLT.      Beitrage  zur   Chirurg.    Statistik.   Langenbeck's  Archiv.   Bd.   25, 

Heft  2. 

KELLY.    Operative  Gynecology.     1898.     1:193. 
MARTIX.    Sarcoma  of  the  Labia  Majora.    Rev.  de  gynec.  et  de  clin.  abdom. 

1913.     31:147- 
MEYER,    P.      Ueber   Melanome   der   ausseren   Genitalien.   Archiv    f.    Gyn. 

85  :512- 
NOBEL.      Zur   Histopathologie   der  venerischen   Bartholinitis.     Archiv     f. 

Dermat.  u.  Syphilis.     Bd.  61.     1902. 
PETERSEN.    Epithelioma  of  the  Vulva.    Amer.  Journ.  Obst.     March,  1904. 

P-  393- 

RIBBERT.     Ueber  des  Melanosarkom.     Ziegler's  Beitrage.     Bd.  21. 
SCHLUTER.     Ein  Fall  doppelseitiger  Sekundarer  Erkrankung  der  Bartho- 

linschen  Driise  an  Karzinom.     Zentr.  f.  Gyn.     1908.     p.  1610. 
SITZENFREY.     Hornkrebs  des  Gang-systems  der  Bartholinschen  Driise,  Zts. 

f.  Geburts  u.  Gyn.     1908.     38:363. 
SPENCER.      Proceedings    Royal    Society    Medicine.      Page    102.       1913. 

i  and  2:102. 
TORGGLER.     Ueber  Melanosarkom.  der  Weiblicheii  Schamtheile.  Monats.  f. 

Geb.  u.  Gyn.     1900.     11:382. 
UNNA.     Histologie  der  Hautkrankheiten.     1894. 
VEIT.     Sarkom  der  Vulva.     Handbuch  der  Gyn.     1:141. 
WAGNER.     Handbuch  der  Allg.  Pathologic.     1876. 


CHAPTER  III 
BENIGN  TUMORS  OF  VAGINA 

Cysts  of  vagina — Frequency — Classification — Etiology — Age — Point  of  origin — Location 
and  appearance — Histology — Types  of  cysts — Epithelial  inclusion  cysts — Cysts  of 
vaginal  glands — Cysts  of  Gartner's  Ducts — Cysts  of  Miiller's  Ducts — Cysts  of  ureter — 
Cysts  of  urethral  gland — Gas  cysts — Echinococcus  cysts- -Symptoms — Diagnosis — 
Differential  diagnosis — Treatment — Fibroma  of  the  vagina — Etiology — Age — Site  of 
origin — Classification — Location — Form,  size  and  appearance — Histology— Occurrence 
with  pregnancy — Symptoms — Diagnosis — Treatment — Prognosis — Literature. 

CYSTS  OF  VAGINA 

Vaginal  tumors  are  even  more  rare  than  vulvar  neoplasms.  Of 
these,  vaginal  cysts  are  by  far  the  most  common.  They  develop,  as 
their  name  implies,  in  the  vaginal  wall,  and  are  of  interest  chiefly  from 
the  standpoint  of  etiology  and  classification,  since  vaginal  cysts  which 
occasion  clinical  symptoms  are  extremely  rare. 

Cysts  of  the  vagina  were  described  as  early  as  1765  by  Haller  and 
at  about  the  same  time  by  Morgagni.  Both  observers,  however,  in- 
correctly considered  them  hydatids.  The  observation  of  Oakley 
Heming  in  1830  is  widely  quoted,  yet  it  appears  that  Hugier,  in  1847, 
first  advanced  the  theory  that  they  arose  from  vaginal  glands.  Hugier 
based  his  belief  on  the  supposition  that  there  were  two  sets  of  vaginal 
glands,  the  superficial,  and  the  deep.  (The  question  as  to  whether 
the  vagina  contains  glands  has  not  been  settled  even  at  the  present 
time.)  Hugier,  however,  believed  that  the  superficial  glands  opened 
into  the  lower  part  of  the  vagina,  and  occasionally  gave  rise  to  thin- 
walled,  superficial  cysts  which  often  were  multiple.  The  deeper  glands 
had  no  outlet  and  were  truly  closed  follicles.  Under  certain  conditions 
in  which  trauma  was  a  factor,  they  developed  into  thick-walled  cysts. 
Eleven  years  later,  Chariere  came  to  rather  similar  conclusions,  but 
thought  that  the  most  common  cause  was  mechanical  injury  to  vaginal 
tissue.  The  subject  remained  in  complete  confusion  until  Winckel,  in 
1871,  collected  50  cases  of  -vaginal- cysts  from  the  literature  and  pre- 
sented a  critical  and  careful  study  based  on  anatomical  facts.  Baum- 
garten,  in  1887,  showed  that  the  histological  picture  aided  in  determin- 
ing the  various  sources  of  origin  of  the  cysts.  In  America,  the  work  of 
Stokes,  in  1898,  and  of  Cullen,  in  1905,  has  done  much  to  elucidate 
many  of  the  perplexing  points  of  the  question. 

42 


BENIGN    TUMORS   OF   VAGINA  43 

Frequency. — Gurlt  found  only  3  cases  in  his  tabulation  of  11,140 
tumors  in  women.  Yet  v.aginal  cysts;  are  far  more  common  than  the 
literature  indicates,  if  we  include  in  our  definition  the  very  small  cysts 
which  give  no  symptoms  and  which  are  discovered  only  accidentally. 
Cysts  of  large  size  are  very  rare.  Only  a  few  have  been  as  large  as 
an  orange.  Only  14  were  the  size  of  a  hen's  egg,  or  larger,  in  the  50 
cases  collected  by  Winckel  in  the  literature  from  1830  to  1871.  Stokes, 
in  1898,  reported  10  cases  in  5,000  gynecologic  cases  in  the  Johns  Hop- 
kins Hospital.  Cullen,  in  1905,  reported  53  cases  observed  during  the 
ten-year  period  from  1893  to  1904  in  the  same  clinic.  To  complete  the 
series,  he  included  Stokes'  cases  in  his  report.  Only  10  cysts  were  the 
diameter  of  an  inch  or  larger. 

Classification. — Under  the  heading  of  vaginal  cysts  are  grouped 
together  a  number  of  primarily  benign  cystic  tumors  of  different  origin 
and  of  varying  size,  appearance  and  location.  Some,  as  J.  Veit,  and 
Stokes,  have  objected  to  classing  as  vaginal  cysts  the  larger  tumors 
which  develop  from  embryological  remnants  in  structures  adjacent  to 
the  vagina,  and  which  are  forced  down  into  the  vagina  as  they  grow. 
The  objection  is  made  that  such  tumors  cannot  be  brought  into  an 
etiological  classification  with  the  true  vaginal  cysts.  Practically,  how- 
ever, for  clinical  purposes  we  must  regard  any  cyst  which  presents 
in  the  vagina  as  a  vaginal  cyst. 

Etiology.— Trauma,  obstetrical  or  surgical,  is  chiefly  responsible 
for  the  cysts  which  result  because  of  the  inclusion,  during  repair  oper- 
ations, of  small  areas  of  vaginal  epithelium  in  the  depths  of  the  wound 
(Fig.  16). 


FIG.   16. — INCOMPLETE  DENUDATION  IN  PERINEORRHAPHY  FROM  WHICH  CYST  MAY  ARISE. 

We  are  ignorant  of  the  causes  which  excite  the  growth  into  cysts 
of  glands  included  within  the  vagina,  and  of  the  embryologic  remnants 
which  are  normally  present  in  the  vaginal  wall. 

Age. — The  great  majority  of  cases  are  noted  during  the  child- 
bearing  age,  yet  they  occur  at  any  time  of  life. 


44  PELVIC  NEOPLASMS 

Point  of  Origin. — Usually  the  point  of  origin  can  be  determined  by 
histological  study.  Vaginal  cysts  may  arise  from 

(a)  Inclusions  of  vaginal  epithelium. 

(b)  Aberrent  vaginal  glands. 

(c)  Gartner's  duct. 

(d)  Miillerian  duct. 

(e)  Lymphatics. 

Location  and  Appearance. — Cysts  may  develop  in  any  part  of  the 
vagina,  yet  there  are  certain  parts  where  they  are  more  commonly 
found.  Stokes  states  that  cysts  of  the  posterior  vaginal  wall  generally 
lie  in  the  median  line;  if  in  the  lateral  vaginal  wall  they  present  usually 
in  the  sulcus  at  the  junction  of  the  lateral  and  posterior  wall.  Cysts 
in  the  anterior  wall  are  more  common  under  the  urethra,  or  on  either 
side.  Some  authors  claim  that  they  are  more  frequently  found  on  the 
right  than  on  the  left  lateral  wall. 

Small  cysts  often  suggest  a  white  grape  in  appearance,  yet  vary 
considerably  according  to  the  thickness  of  the  wall,  the  character  of 
their  contents,  and  the  depth  in  which  they  lie  in  the  tissue.  The  wall 
may  be  thin  or  thick,  and  may  contain  clear,  milky,  or  thick,  tenacious, 
chocolate-colored  fluid.  The  larger  cysts  are  often  egg-shape,  with  the 
long  axis  parallel  to  the  long  axis  of  the  vagina.  Their  color  may  be 
pale  or  opaque,  depending  largely  upon  the  type  of  their  contents  and 
the  thickness  of  the  wall. 

The  position  of  the  cyst  is  of  some  value  in  deciding  its  etiology. 
For  example,  a  cyst  of  the  posterior  wall  cannot  arise  from  a  dilatation 
of  the  duct  of  Gartner,  since  this  type  lies  in  the  lateral  vaginal  wall. 
A  cyst  following  the  course  of  the  vagina,  or  winding  about  it,  suggests 
an  origin  from  mullerian  tissue. 

Histology. — The  histological  picture  varies  according  to  the  struc- 
tures from  which  the  tumor  has  originated.  Since  glands  may  arise 
from  inclusions  of  stratified  epithelium,  or  from  embryological  rem- 
nants containing  cuboidal  epithelium,  or  from  lymphatics,  it  follows 
that  the  lining  of  the  cysts  may  present  different  cell  pictures.  Thus, 
ciliated  columnar  epithelium,  low  cuboidal,  or  stratified  squamous 
epithelium  may  constitute  the  lining.  Occasionally,  cysts  are  lined  with  squa- 
mous epithelial  cells,  the  superficial  layers  of  which  are  vacuolated  and  devoid 
of  nuclei.  Other  cysts  may  be  found  which  contain  both  cuboidal  and 
squamous  cell  epithelium  in  their  lining  membrane.  These  cases  de- 
velop from  ducts  or  glands  which  are  lined  by  cylindrical  epithelium, 
although  the  neck  of  the  duct  or  gland  ends  in  squamous  epithelium. 
Other  cysts  may  not  present  an  epithelial  lining,  the  cells  having  been 
killed  by  pressure  atrophy. 

The  cyst  contents  vary  from  clear  serous  to  turbid  and  even  hemor- 
rhagic  material;  calcareous  deposits  have  been  found  in  the  walls 


BENIGN    TUMORS    OF    VAGINA 


45 


(vaginal  calculi).  The  consistency  and  appearance  of  the  cyst  con- 
tents depend  upon  the  amount  and  type  of  the  solid  substances  sus- 
pended in  solution.  Desquamated  epithelium,  fatty  debris,  cholesterin 
crystals,  and  blood  have  been  found  in  the  fluid. 

Types  of  Cysts — EPITHELIAL  INCLUSION  CYSTS. — By  far  the  largest 
number  of  vaginal  cysts  have  developed  from  tags  of  vaginal  mucosa,  which 


FIG.  17. — VAGINAL  INCLUSION  CYST  (Kelly,  Operative  Gynecology). 

were  buried  in  the  repair  of  vaginal  tears  following  labor  or  from  faulty 
denudation  in  secondary  vaginal  repairs  (Fig.  16).  They  may  also  follow 
adhesive  vaginitis  from  any  cause  which  results  in  abrasions  of  the  surfaces 
of  the  vagina,  so  that  agglutination  follows.  Usually  they  are  small,  ranging 
in  size  from  a  few  millimeters  to  2  or  3  centimeters,  and  generally  are  single. 


46  PELVIC  :  NEOPLASMS 

They  are  found  most  often  in  ".the  posterior,  or  lower  lateral  walls  of  the 
vagina,  frequently  at:the  site'af  an  old.  tear.  .They  are  yellow  or  white  in 
color,  and  have  thin',}  smooth  walls  from  2  .to  3  millimeters  in  thickness. 
The  inner  surface  is  smooth.  They  contain  a  friable  material,  of  yellow 
color,  which  slightly -resembles  pus,  but'-w'hi'ch  -actually  -consists  of  exfoliated 
squamous  epithelium  ( Fig.  ,17). 

Histologically,  the  vaginal  mucosa  attached  to  the  cyst  is  usually  normal, 
yet  may  be  atrophic  from  pressure  of  the  cyst.  The  cyst  walls  are  of  fibrous 
tissue,  lined  by  a  varying  number  of  cells  of  squamous  epithelium.  The 
epithelial  covering  ranges  from  two  to  thirty  layers  of  cells  (Cullen)  and 
occasionally  is  of  uniform  thickness  throughout,  yet  more  often  contains 
thick  and  thin  areas.  The  superficial  epithelial  layers  contain  no  nuclei  and 
the  cells  are  vacuolated.  The  deepest  layer  is  cuboidal. 

CYSTS  ARISING  FROM  VAGINAL  GLANDS. — The  existence  of  vaginal 
glands  has  been  much  questioned.  Eppinger,  Nagel,  Gebhard,  Pretti,  Wal- 
deyer,  Williams,  and  others  deny  their  existence.  Nor  have  we  ever  seen 
them  in  the  examination  of  a  large  number  of  specimens.  On  the  other 
hand,  Hennig  described  them  in  1870,  and  von  Preuschen  in  1877  found 
definite  glands  in  the  vagina  in  4  of  the  36  bodies  which  he  examined. 
Cullen  also  states  that  they  are  occasionally  met  with. 

Yet  glands  which  are  found  so  rarely  cannot  be  considered  as  a  constant 
structure  of  the  vagina.  Von  Preuschen,  as  a  result  of  his  study,  stated 
that  the  vaginal  glands  seen  by  him  presented  a  structure  rather  similar  to 
the  sebaceous  glands  of  the  vulva,  consisting  of  a  broad,  baylike  portion, 
together  with  several  fingerlike  tributaries  which  were  filled  with  a  dull, 
glistening  mass  resembling  fat.  The  main  portion  of  the  gland,  the  baylike 
formation,  is  lined  with  squamous  epithelium.  In  the  tributaries  which  lie 
deeper  in  the  vagina,  the  superficial  layers  of  the  squamous  epithelium  have 
disappeared,  and  the  lining  of  these  smaller  glands  is  of  ciliated  cylindrical 
epithelium. 

The  structures  described  by  von  Preuschen  lie  in  the  upper  portion  of 
the  vagina.  Since  they  have  been  sought  so  unsuccessfully  by  so  many 
others  and  were  found  by  von  Preuschen  in  only  4  of  his  36  cases,  the 
majority  of  gynecologic  pathologists  class  most  of  these  structures  as 
aberrant-cervical  glands.  The  cases  of  Cullen,  however,  are  more  difficult 
to  dispose  of.  The  similarity  of  Hugier's  and  von  Preuschen's  observations 
are  worthy  of  comment. 

Cullen  feels  that  three  of  the  cysts  described  by  him,  and,  possibly  a 
fourth,  were  derived  from  vaginal  glands.  The  3  cases  were  noted  in  young 
women  who  had  perineal  lacerations  for  which  they  had  come  for  operation. 
The  cysts  were  found  in  the  resected  mucosa  of  the  posterior  vaginal  wall, 
lying  by  the  side  of  definite  inclusion  cysts.  The  cysts  were  small,  from 
6  millimeters  to  1.5  centimeters  in  size  and  were  lined  by  cuboidal  epi- 
thelium, which  was  flattened  in  2  of  the  3  cases.  The  cysts  contained  mucus, 
with  no  evidence  of  desquamated  epithelium  which  Cullen  believes  would 


BENIGN    TUMORS    OF    VAGINA  47 

surely  have  been  present  had  the  cysts  been  lined  primarily  with  squamous 
epithelium.  Stokes  also  reports  a  case  removed  by  C.  P.  Noble  because  of 
symptoms,  in  which  the  cyst  was  8  by  5  centimeters  and  was  lined  by  a 
single  layer  of  high  columnar  epithelium,  which  Stokes  believes  was  a  true 
prototype  of  that  found  in  the  cervix. 

CYSTS  OF  GARTNER'S  DUCTS. — Gartner's  ducts  in  the  embryo  may  be 
traced  from  the  parovarian  tubules  (wolffian  body)  in  the  mesosalpinx 
down  through  the  broad  ligament,  either  in  or  at  the  side  of  the  uterus, 
down  as  far  as  the  cervix.  From  here  it  may  extend  down  either  to  the 
anterior  or  the  lateral  wall  of  the  vagina,  and  even  as  far  as  the  outlet.  On 
cross  section,  the  duct  shows  an  outer  covering  of  fibrous  tissue,  a  middle 
zone  of  smooth  muscles  arranged  longitudinally  and  transversely,  and  an 
inner  lining  of  simple  cuboidal  or  cylindrical  epithelium.  In  the  majority 
of  cases,  the  duct  disappears,  but,  in  a  few  instances,  portions  or  all  of  the 
duct  persist  in  adult  life.  As  the  result  of  accumulated  secretions,  the 
duct  may  become  cystic.  If  only  one  segment  of  the  duct  persists,  dilatation 
gives  rise  to  a  single  cyst ;  if  several  patent  segments  of  the  duct  are  sep- 
arated by  atretic  portions,  multiple  cysts  may  develop.  These  ducts  are 
usually  small  and  may  suggest  a  string  of  beads,  as  did  the  case  of  Debierre. 
In  rare  instances,  the  duct  may  be  patent  from  the  parovarium  to  the  vagina, 
and  cystic  dilatation  may  give  rise  to  a  mass  extending  up  into  the  broad 
ligament  and  occasionally  down  beneath  the  vagina.  Cysts  of  this  type  may 
be  as  large  as  a  child's  head.  They  are  very  rare. 

Cysts  originating  from  the  portion  of  Gartner's  duct  situated  in  the 
vaginal  wall  are  comparatively  frequent,  and  lie  in  the  anterior  or  lateral 
vaginal  wall  (Fig.  18).  They  may  be  exceedingly  small  but  usually  are 
several  centimeters  in  size.  Usually  they  are  not  perfectly  globular  but 
cylindric  or  funnel-shaped,  corresponding  to  the  long  axis  of  the  vagina. 
The  cyst  walls  are  of  variable  thickness  (i  to  2  millimeters)  and  contain 
clear  or  straw-colored  fluid.  Histologically,  the  walls  are  made  up  of 
fibrous  and  muscle  tissue  and  are  lined  with  cylindric  or  cuboidal  epithelium. 
The  overlying  vaginal  mucosa  may  be  atrophic.  A  small  stem  may  be  seen 
leading  from  the  cyst,  probably  representing  a  more  rigid  portion  of  the 
duct  (Cullen). 

CYSTS  ARISING  FROM  MULLER'S  DUCTS. — Cysts  arising  from  this  source 
are  present  only  when  the  two  mullerian  ducts  failed  to  meet.  As  a  result, 
there  are  two  uteri  and  two  vaginae.  Cysts  can  only  arise  when  one  vagina 
is  well  developed  and  the  other  is  represented  only  by  a  rudimentary  cord 
which  becomes  fused  in  the  wall  of  the  well-developed  vagina.  Secretions 
accumulating  in  the  atrophic  vaginal  tube  cause  a  cystic  dilatation  which 
appears  to  spring  from  the  lateral  vaginal  wall  (Fig.  19). 

Occasionally  both  uteri  are  fairly  well  developed,  yet  one  vagina  has  no 
lower  outlet,  and  is  in  reality  only  a  blind  sac.  With  menstruation,  there 
results  a  cyst  containing  menstrual  fluid  which  gradually  becomes  chocolate 
brown  in  color.  Freund,  in  1877,  called  attention  to  this  deformity,  and 


48 


PELVIC   NEOPLASMS 


since  then  Kleinwachter  has  collected  other  cases.  The  tension  of  the  cyst 
is  sometimes  sufficient  to  break  the  lower  wall  of  the  sac  so  that  the  fluid 
may  drain  through  the  developed  vagina.  Infection  may  be  present  before 
the  cyst  opens  (Fig.  20). 


FIG.  1 8. — CYST  IN  VAGINA  (Kelly,  Operative  Gynecology). 

CYSTS  DEVELOPING  FROM  THE  URETER. — Cysts  originating  from  a 
pouch  of  a  misplaced  ureter  are  occasionally  met  with,  from  which  urine 
escapes  when  opened.  Occasionally,  as  a  result  of  trauma,  fistulous  open- 
ings are  seen  through  which  urine  is  discharging.  Such  cases  are  usually 
seen  when  two  kidneys  or  two  ureters  exist  on  one  side.  Broedel  has  shown 
that  when  this  state  exists,  the  ureter  from  the  lower  kidney  is  more  apt  to  be 


BENIGN    TUMORS    OF    VAGINA 


49 


inserted  in  the  normal  site  than  is  the  other  one.  The  ureter  of  the  upper 
kidney  is  apt  to  be  carried  down  further  with  the  wolffian  duct  to  empty 
more  mesially  near  the  internal  urethral  orifice,  while  occasionally  it  forms 
a  blind  sac. 

CYSTS  ARISING  FROM  URETHRAL  GLANDS. — Cullen  thinks  it  unlikely 
that  cysts  develop  from  urethral  glands,  although  the  possibility  cannot  be 
denied.  The  cases  which  appear  to  arise  from  such  structures  may  equally 
well  be  ascribed  to  remnants  of  Gartner's  ducts  unless  a  connection  with  the 


FIG.  19.  FIG.  20. 

FIG.  19. — VAGINAL  CYST  ARISING  FROM  IMPERFECT  UNION  OF  MULLER'S  DUCT. 

(Schematic  after  Cullen.) 

FIG.  20. — VAGINAL  CYST  REPRESENTING  IMPERFORATE  AND  RUDIMENTARY  VAGINA 

OF  RIGHT  SIDE. 

urethra  can  be  proved.  The  lining  of  these  cysts  (usually  small)  is  made  up 
of  several  layers  (three  to  eight)  of  cylindrical  cells  lying  upon  flattened 
cells  which  take  a  deep  stain. 

GAS  CYSTS. — Various  names  have  been  advanced  to  designate  these  rare 
cysts  which  are  usually  observed  during  pregnancy.  Winckel  termed  them 
colpohyperplasia  cystica,  Eppinger  designated  them  as  emphysema  vagina, 
and  Ruge  called  them  colpitis  vesicula  emphysematosa. 

They  were  described  by  Braun  in  1861  and  ten  years  later  by  Winckel, 
who  reported  3  cases,  since  when  they  have  been  reported  occasionally. 
They  are  usually  small,  superficial,  transparent,  thin-wall  cysts,  closely 
grouped  together  on  the  injected  swollen  anterior  or  posterior  walls.  There 
were  a  great  number  of  tiny  cysts  in  one  of  Winckel's  cases,  so  closely 
packed  together  "that  a  dollar  would  cover  15  or  20."  The  cyst  wall  is  a 


50  PELVIC  NEOPLASMS 

thin  layer  of  connective  tissue  without  a  lining  of  epithelium.  On  puncture, 
gas  escapes  with  an  audible  noise.  There  is  no  fluid  in  the  cavity.  Eisen- 
lohr  believes  that  these  little  cysts  are  due  to  some  gas-producing  organism 
which  develops  in  the  lymphatics.  We  know  nothing  positive  about  their 
true  origin.  They  disappear  spontaneously  during  the  puerperium. 

ECHINOCOCCUS  CYSTS. — Echinococcus  cysts  may  develop  in  the  vagino- 
rectal  septum  and  project  into  the  vagina.  Occasionally  they  attain  con- 
siderable size.  The  echinococcus  can  be  demonstrated  in  the  cyst  with  the 
microscope. 

Symptoms. — The  smaller  cysts  rarely  cause  symptoms,  and  as  a 
rule  are  discovered  accidentally.  The  larger  cysts  may  give  symptoms 
from  pressure  and  occasionally  offer  obstruction  to  both  coitus  and 
labor.  Cysts  of  the  posterior  wall  may  roll  out  the  pelvic  floor  and 
simulate  prolapse.  The  larger  cysts  have  occasionally  formed  an 
efficient  barrier  to  birth.  Giider  reported  3  such  cases  and  collected 
20  others  from  the  literature  in  1889,  several  of  them  being  echino- 
coccus cysts.  The  case  of  Peters  is  especially  worthy  of  comment.  In 
this  case,  one  pound  of  clear  fluid  was  removed  from  the  cyst  with  a 
trocar  before  the  walls  collapsed  sufficiently  to  allow  advance  of  the 
child's  head.  The  large  cysts  which  extend  up  into  the  broad  ligament 
give  rise  to  various  symptoms  depending  upon  the  size  and  position  of 
the  growth.  The  tumor  may  make  pressure  on  the  uterus,  ureter, 
bladder  and!  rectum  and  nerves  of  the  pelvis.  They  may  give  rise  to 
bearing-down  sensations  and  may  even  interfere  with  locomotion.  The 
cysts  are  not  tender. 

Diagnosis. — There  should  be  little  difficulty  in  the  diagnosis  pro- 
vided the  physician  proceeds  in  a  methodical  manner.  These  tumors 
usually  grow  very  slowly,  although  they  may  enlarge  rapidly  during 
pregnancy.  They  tend  to  grow  in  the  direction  of  least  resistance,  con- 
sequently, they  may  grow  along  in  the  rectovaginal  septum,  before 
developing  in  the  cavity  of  the  vagina  or  the  rectum.  They  may 
indeed  grow  away  from  the  vagina  into  the  broad  ligament  until  they 
encounter  resistance  sufficient  to  force  the  growth  downward. 

The  cysts  usually  feel  soft  and  elastic,  and  give  the  sensation  of 
fluctuation,  yet  when  greatly  distended  they  may  be  so  firm  and  resist- 
ant that  they  suggest  a  fibroid.  The  physician  will  do  well  to  examine 
first  with  a  speculum  before  making  the  bimanual  and  rectovaginal 
examination. 

Differential  Diagnosis. — These  cysts  may  be  confused  with  soft 
vaginal  fibroids,  cystocele,  rectocele,  hernias,  and  hydrocele  of  the 
canal  of  Nuck. 

Treatment. — The  treatment  is  excision  in  all  cases.  The  smaller 
cysts  can  readily  be  removed  and  the  cavity  sutured  with  chromic  cat- 
gut. The  removal  of  the  larger  vaginal  cysts  may  be  difficult  because 
of  lack  of  exposure  and  the  presence  of  hemorrhage.  Occasionally,  it  is 


BENIGN    TUMORS    OF   VAGINA  51 

more  wise  to  remove  part  of  the  growth  and  unite  the  remaining  edges 
with  the  vagina,  so  that  eventually  the  part  of  the  cyst  wall  that  is  left 
becomes  part  of  the  vagina.  The  larger  vaginoparovarian  type  of  cyst 
may  present  interesting  surgical  problems,  and  abdominal  operations 
are  usually  necessary.  Occasionally  it  may  be  quite  impossible  to 
remove  the  sac.  The  growth  may  then  be  treated  with  marsupializa- 
tion.  One  should  always  keep  in  mind  that  swellings  in  the  anterior 
vaginal  wall  may  prove  to  be  a  dilated  blind  ureter,  the  incision  of 
which  may  create  a  urinary  fistula. 


FIBROMYOMA  OF  THE  VAGINA 

Fibromyoma  rarely  originates  in  the  vagina.  Breisky,  in  1886, 
collected  58  cases;  Smith,  in  1902,  100  cases;  and  Potel,  in  1903, 
extended  the  list  to  150  cases.  Miiller,  in  1914,  and  Giesecke,  in  1915,  have 
made  careful  studies,  the  latter  author  citing  196  cases. 

Etiology. — The  causal  factors  are  not  known.  The  same  theories 
which  have  been  advanced  to  explain  uterine  fibroids  and  the  adeno- 
myoma  (q.  v.)  obtain  here. 

Age. — The  majority  of  cases  are  noted  in  the  third  and  fourth 
decades.  Cases  in  children  have  been  observed,  although  there  is 
doubt  as  to  whether  they  are  true  fibroids.  Many  state  that  they 
belong  to  the  sarcoma  or  teratoma.  Martin  observed  a  case  in  a  new- 
born child.  Tratzels'  case  was  fifteen  months  old.  Wilson's  case  was 
two  and  one-half  years. 

Site  of  Origin. — The  fibroid  tumors  develop  from  the  connective 
tissue  of  the  vaginal  wall,  or  from  the  coats  of  the  musculature.  Many 
claim  that  the  growths  which  develop  from  the  cross-striated  muscle 
usually  belong  to  the  sarcoma. 

Classification. — Fibroids  which  have  their  origin  in  the  uterus,  but 
which  have  grown  down  into  the  connective  tissue  and  are  forcing  their 
way  into  the  vagina,  are  excluded  from  the  classification.  In  the  same 
manner,  pedunculated  growths  from  the  cervix  which  have  become 
adherent  to  the  vagina  do  not  belong  to  this  category.  Here  belong 
only  such  growths  as  have  originated  in  the  structures  of  the  vagina. 

Properly  speaking,  the  tumors  may  be  fibroids,  myomata,  or  fibro- 
myomata,  depending  upon  the  character  of  their  prevailing  tissue. 
Practically  they  are  all  grouped  as  fibroids.  The  adenomyomata,  how- 
ever, form  a  distinct  division  and  are  considered  separately. 

Location. — The  vaginal  fibroids,  like  the  sarcoma,  usually  develop 
on  the  anterior  vaginal  wall,  in  contrast  to  the  carcinoma  which 
develops  on  the  posterior  wall. 

Form,  Size  and  Appearance. — The  tumors  are  usually  single,  but 
may  be  multiple.  They  consist  of  hard,  round,  nodular  tumors,  which, 


52  PELVIC  NEOPLASMS 

though  usually  of  small  size,  may  attain  considerable  dimensions,  even 
more  than  five  or  six  inches  in  diameter.  Emmel's  case  weighed  625 
grams.  They  grow  from  beneath  the  mucosa  into  the  vagina,  and  in 
consequence,  finally  develop  a  pedicle,  if  they  are  not  removed  prior  to 
that  stage.  Usually,  they  are  encompassed  by  a  fibrous  capsule.  They 
are  covered  by  the  vaginal  mucosa  on  their  vaginal  surface,  which  is 
often  excoriated  or  ulcerated,  following  friction.  The  cut  surfaces  pre- 
sent the  typical  fibroid  appearance,  and  often  present  macroscopic 
evidence  of  degenerations. 

Histology. — Histologically  the  tumor  is  made  up  of  smooth  muscle 
bundles  and  connective  tissue  in  variable  proportions.  Degenerations 
are  common,  similar  to  those  of  uterine  fibroids  (q.  v.).  Edema  is  so 
frequent  as  nearly  to  constitute  the  rule  in  the  larger  tumors. 

Complications. — The  tumor  may  undergo  various  degenerations 
from  which  symptoms  may  occur.  Sarcomatous  changes  have  been 
noted. 

Occurrence  with  Pregnancy. — The  growth  is  an  occasional  accom- 
paniment of  pregnancy.  It  may  enlarge  tremendously  from  edema  as 
well  as  actual  hypertrophy,  just  as  do  uterine  fibroids.  A  series  of 
vaginal  fibroids  and  pregnancy  has  been  collected  by  Giider,  in  which 
there  was  i  spontaneous  birth  in  the  presence  of  the  tumor,  3  forceps, 
2  versions,  i  breech  extraction  and  3  cesareans.  The  tumor  was  re- 
moved before  labor  in  four  instances,  and  once  shortly  before  birth 
which  resulted  spontaneously. 

Symptoms. — Usually  there  are  no  symptoms  in  the  smaller  growths 
which  are  found  accidentally,  unless  the  tumor  has  become  ulcerated 
and  has  occasioned  a  foul-smelling  leukorrhea.  Da  Costa  described  a 
case  which  projected  from  the  vulva  and  measured  6  by  4.5  inches. 
Simpson's  case  was  the  size  of  two  fists  and  interfered  with  micturition 
and  the  escape  of  the  uterine  discharges.  As  a  rule,  the  larger  growths 
cause  bearing-down  pains  and  pelvic  pressure  symptoms,  especially 
upon  the  bladder  and  rectum.  Dyspareunia  is  common. 

Diagnosis. — The  diagnosis  is  readily  apparent  in  the  very  great 
majority  of  cases.  It  may  be  difficult  in  cases  which  block  the  vagina, 
where  the  site  cannot  be  ascertained,  since  the  pedicle  cannot  be 
reached.  There  is  usually  no  doubt  that  the  tumor  is  a  fibroid.  The 
differential  diagnosis  is  made  chiefly  from  vaginal  cysts. 

Treatment. — The  treatment  is  surgical  removal,  which  usually 
occasions  no  difficulty.  Pedunculated  tumors  are  easily  ligated  and 
removed,  after  which  the  vaginal  edges  are  brought  smoothly  together. 
The  sessile  tumors  are  removed  after  exposure  through  a  linear 
incision  when  the  tumor  is  shelled  out  from  its  capsule.  The  hemor- 
rhage should  be  controlled  and  the  raw  edges  brought  together  with 
chromic  catgut.  A  vaginal  pack  promotes  healing  if  left  in  for  twenty- 
four  hours. 


BENIGN    TUMORS    OF   VAGINA  53 

The  larger  growths  may  be  difficult  to  expose,  and  episiotomy  or 
even  a  large  paravaginal  incision  may  be  found  necessary.  Healing  is 
usually  by  first  intention  if  there  was  proper  wound  approximation. 
There  are,  however,  numerous  instances  of  infection. 

Prognosis. — The  prognosis  is  good.     The  growth  does  not  recur. 


LITERATURE 

BREISKY.     Die  Krankheiten  der  Vagina.     1886.     S.  162. 

CULLEN.    Vaginal  Cysts.  Johns  Hopkins  Hospital  Bulletin.    1905.    16:206. 

GEBHARD.     Cysten  der  Vagina.     Pathologische  Anatomic  der  Weiblichen 

Sexualorgane.     1899.     P.  535. 
GIESECKE.     Muskel-Bindegewebsgeschwiilste  der  Vaginalwand.     Zentralbl. 

fur.  Gyn.     1915.     39,  S.  81. 
KLEIN.     Die  soliden  primaren  Geschwiilst  der  Scheide.     Monatsschr.   f. 

Geb.  u.  Gyn.     1898.     7:  564. 

MULLER.     Vaginalmyome.     Arch.  f.  Gyn.     1914.     102:511. 
POTEL.     Le  fibromyom  du  vag.     Rev.  de  Gyn.     1903.    3. 
PREUSCHEN,  v.     Ueber  Cystenbildung  in  der  Vagina.     Virchow's  Archiv. 

1877.    Bd.  70:111. 
SMITH.     Fibromyomatous  Tumors  of  the  Vagina.     Am.  J.  Obst.     1902. 

i:  145. 

STOKES.     True  Vaginal  Cysts.     Johns  Hopkins  Hospital  Reports.     7:109. 
VEIT.     Handbuch  der  Gyn.,  erste  Halfte.     3:  290. 


CHAPTER  IV 

MALIGNANT  TUMORS   OF  VAGINA 

Carcinoma  of  vagina — Frequency — Etiology — Classification — Location — Primary  growths, 
appearance  and  form — Histology — Method  of  growth — Complications  with  pregnancy 
— Symptoms — Diagnosis — Prognosis — Sarcoma  of  vagina — 'Classification — Sarcoma  in 
infancy — Etiology — Age — Point  of  origin — Location — Appearance — Method  of  growth 
— Histology — Symptoms — Duration — Diagnosis  —  Prognosis  —  Therapy — Sarcoma  of 
adult — Classification — Etiology — Age — Appearance — Location — Histology —  Method  of 
growth — Symptoms — Diagnosis — Prognosis — Treatment — Radium — Literature. 

CARCINOMA  OF  THE  VAGINA 

Carcinoma  of  the  vagina  may  be  primary  or  secondary. 

Primary  carcinoma  is  rare.  Various  attempts  have  been  made  to 
determine  its  frequency,  as  may  be  seen  by  the  following: 

In  59,600  cases,  Gurlt  found  114  carcinoma  of  the  vagina  (.19  per 
cent). 

In  35,807  gynecologic  patients  in  Berlin,  Schwarz  found  84  (.24  per 
cent). 

In  10,000  gynecologic  patients  in  Berlin,  Hofmeier  found  .11  per 
cent. 

In  18,000  gynecologic  patients  in  Halle,  Rohde  found  .06  per  cent. 

In  8,981  gynecologic  patients  in  Prague,  1875  to  1891,  there  were 
38  cases  (.42  per  cent). 

It  was  found  14  times  in  8,287  women  (.16  per  cent)  who  died  of 
cancer  in  France  (Beigel). 

Gurlt's  statistics  show  1.5  per  cent  in  7,479  carcinomatous  women; 
and  .77  per  cent  (15  cases)  of  1,924  carcinomatous  women  in  Vienna. 
Williams  states  that  it  formed  .43  per  cent  of  the  carcinoma  in  his 
series. 

Friedl  found  it  once  for  every  63  uterine  carcinomata  in  Vienna  and 
Prague.  He  also  expressed  the  belief  that  primary  carcinoma  may  be 
more  frequent  than  is  usually  considered  for  the  following  reason:  The 
cancer  usually  begins  on  the  posterior  vaginal  wall  very  close  to  the 
vaginal  portion  of  the  cervix.  Its  tendency  in  growth  is  to  extend  up 
to  the  posterior  cervix.  Thus  a  late  growth  coming  late  to  treatment 
in  which  the  cervix  has  been  widely  involved  by  extension  from  the 
vaginal  tumor  is  extremely  likely  to  be  diagnosed  as  vaginal  involve- 
ment secondary  to  an  inoperable  cervical  cancer. 

54 


MALIGNANT  TUMORS  OF  VAGINA  55 

Etiology. — Nothing  is  known  as  to  the  cause  of  this  affection. 
Heredity  and  trauma  during  childbirth  have  not  been  shown  to  have 
a  close  relationship  as  in  cervical  cancers.  It  is  a  disease  of  advanced 
life  but  has  been  observed  as  early  as  the  twenty-sixth  year.  Rhode 
analyzed  the  ages  of  130  cases  and  found  nearly  all  between  the  thir- 
tieth and  sixtieth  years.  A  close  relationship  to  the  menopause  is  not 
proved,  and  the  old  theory  that  ovarian  secretions  inhibit  the  growth 
during  menstrual  life  is  combated  by  numerous  instances  which 
occurred  during  that  period.  The  cancer  has  been  found  in  young  and 
old,  virgin  and  parous. 

The  majority  of  theories  advanced  as  exciting  causes  by  the  older 
observers  centered  about  trauma.  Chief  of  these  is  the  irritation  from 
pessaries,  since  a  number  of  cases  have  been  described  where  pessaries 
which  had  been  worn  continuously  for  years  were  found  imbedded  in 
carcinomatous  tissue.  This  factor,  while  real,  accounts  for  very  few 
cases,  as  is  shown  by  Wille,  who  collected  the  list.  Yet  pessaries  are 
so  commonly  worn,  and  so  many  cases  have,  been  seen  where  they  have 
been  retained  literally  for  years  in  an  inflammatory  mass,  that  we  are 
forced  to  believe  that  the  vagina  is  relatively  immune  to  such  insults; 
otherwise  cancer  would  more  often  occur. 

This  theory  of  mechanical  insult  appears  to  receive  some  support 
from  the  fact  that  carcinoma  has  occurred  in  cases  of  prolapsed  vagina. 
Vet  this  list  is  small.  Rhode,  in.  1897,  could  collect  only  4  cases  besides 
his  own,  which  is  all  the  more  interesting  because  operations  for  pro- 
lapse were  rare  at  that  time.  Nearly  all  cases  were  treated  with 
pessaries.  Veit,  in  1908,  adds  only  3  other  cases  to  Rhode's  list. 

Efforts  to  link  the  etiology  with  chronic  inflammations,  as  repeated 
gonorrhea  and  syphilis,  have  not  been  successful.  The  theory  of  the 
infectiousness  of  carcinoma  is  confirmed  by  at  least  one  instance  of 
marital  infection  of  wife  and  husband  (Wolowski). 

Classification. — Primary  growths  are  usually  epithelioma,  chiefly 
of  the  papillary  or  cancroid  type.  More  rarely  they  are  infiltrating.  A 
few  adenocarcinomata  have  been  described,  originating  in  preformed 
vaginal  cysts  (R.  Meyer,  Bail  and  Beyen). 

Secondary  carcinoma  may  be  either  squamous  cell  epithelioma  or 
adenocarcinoma,  depending  upon  the  type  of  the  original  tumor. 

Location  of  Growth.— Primary  carcinoma  is  usually  found  high  on 
the  posterior  wall  near  the  vaginal  portion  of  the  cervix.  The  ring- 
type  form  may  occur  at  a  lower  level.  Rhode  gives  the  location  of  the 
growth  in  123  cases  as  follows: 

Posterior  vaginal  wall 71 

Anterior  vaginal  wall 23 

Lateral  vaginal  wall 13 

Ring-type  encircling  vagina 16 


5  6  PELVIC  NEOPLASMS 

Primary  Growths,  Appearance  and  Form. — The  everting  type  is 
far  the  more  common.  It  presents  in  early  cases  as  a  fungating  mass 
which  projects  slightly  above  the  vaginal  tissue.  The  edges  are  clearly 
cut.  The  growth  moves  readily  in  the  deeper  tissues,  but  is  friable  and 
bleeds  readily.  Ulceration  comes  on  early  and  there  is  secondary  infec- 
tion. The  surface  sloughs  and  is  replaced  by  a  typical,  crater-form, 
carcinomatous  ulcer.  The  margins  extend  farther  beyond  the  mucosa 
than  is  apparent  by  inspection.  The  whole  mass  is  fixed  in  a  stiff, 
infiltrated  base. 

The  infiltrating  type  of  primary  carcinoma  is  rarely  seen.  It  pre- 
sents a  diffuse  infiltration,  giving  the  impression  of  a  dense  mass  of 
tiny,  firm  nodules.  The  edges  are  not  discrete.  Extensions  are  irreg- 
ular in  shape;  occasionally  the  growth  completely  encircles  the  vagina. 
This  type  is  analogous  to  the  infiltrating  cancers  of  the  cervix,  where 
extension  into  the  adjacent  tissue  is  an  extremely  early  process.  The 
circulation  of  the  vagina  is  so  good  that  slough  occurs  only  as  a  late 
process.  Superficial  excoriations,  however,  are  common.  The  whole 
mass  is  brawny,  and  from  the  very  start  is  fixed  upon  the  underlying 
tissues.  The  vagina  is  vascular,  and  is  excoriated  by  the  irritating 
fetid  discharge.  Contraction  of  the  surfaces  occurs  early,  and  the  ring- 
form,  circular  type  may  constrict  the  vagina  so  that  it  scarcely  admits 
a  finger.  This  type  of  growth  shows  less  tendency  to  infiltrate  deeply 
than  other  infiltrating  forms  of  carcinoma. 

Histology. — Naturally  the  primary  cancers  which  originate  from 
the  squamous  epithelium  present  the  characteristic  picture  of  the 
squamous  epithelioma.  The  surface  epithelium  may  be  somewhat 
thickened,  and  may  contain  necrotic  tissues,  but  the  true  character  of 
the  growth  is  shown  at  the  margins  of  the  tumor.  The  interpapillary 
processes  are  lengthened,  branched  and  anastomosed,  and  are  seen 
invading  the  underlying  tissue.  The  epithelial  nests  stand  out  in  sharp 
contrast  to  the  normal  epithelium. 

The  primary  adenocarcinomata  from  vaginal  cysts  are  typical  cylin- 
drical-cell carcinomata. 

The  secondary  cancers  reproduce  the  original  growth  in  slightly 
altered  form.  Both  squamous-cell  epithelioma  and  adenocarcinoma 
have  been  described. 

Method  of  Growth. — The  fundamental  processes  of  both  types  of 
primary  cancers  are  identical.  The  chief  difference  is  the  rapidity  with 
which  extensions  occur.  In  the  papillary  growths,  there  is  a  short 
latent  period  in  which  extension  is  not  rapid  unless  ulceration  occurs. 
On  the  contrary,  the  indurating  type  early  invades  the  adjacent  tissues. 

Extensions  progress  very  quickly  from  the  mucosa  to  the  depths, 
since  the  poorly  developed  vaginal  tissue  offers  little  resistance  to  the 
further  spread.  The  cancer  progresses  by  direct  extension  out  under 
the  mucosa  to  the  rectum  and  broad  ligament,  and  rather  rarely  to  the 


MALIGNANT  TUMORS  OF  VAGINA  57 

bladder.  It  quickly  reaches  the  cervical  tip,  often  by  contact  infection, 
but  finally  by  direct  extension.  More  rarely  does  it  extend  down  to 
the  vulva. 

The  lymphatic  channels  are  early  invaded,  and  the  pelvic  glands 
become  involved.  The  inguinal  glands  receive  metastasis  if  the 
primary  growth  is  in  the  lower  vagina.  The  broad  ligaments  become 
infiltrated,  with  the  result  that  there  is  compression  and  involvement  of 
the  ureters.  General  carcinomatosis  occurred  only  twice  in  Rhode's 
series  of  130  collected  cases. 

Complication  with  Pregnancy. — The  growth  has  frequently  been 
observed  as  a  complication  of  pregnancy.  Rhode  collected  12  cases. 
The  mother  died  in  10  cases  (83  per  cent)  and  the  child  in  7  cases  (58 
per  cent).  Only  twice  was  there  spontaneous  birth.  There  were  4 
cesareans  with  2  maternal  deaths ;  2  inductions  of  labor  with  2  maternal 
deaths.  The  disease  progresses  very  rapidly  during  pregnancy. 

Symptoms. — The  symptoms  at  first  are  slight.  Leukorrhea,  a  thin, 
watery,  irritating  discharge  is  the  earliest  symptom,  and  may  be  of  long 
standing  before  there  is  blood.  Hemorrhage  often  follows  coitus  or 
straining  at  stool.  Later  there  is  backache,  and  pain,  and  usually  dis- 
turbances of  the  bladder  and  bowels.  With  the  compression  of  the 
ureters,  there  is  uremia  and  infection,  although  a  rectovaginal  fistula 
may  occur  before  this  develops.  Rarely  there  is  a  vesicovaginal  fistula. 
Death  comes  as  a  rule  from  cachexia. 

Diagnosis. — The  diagnosis  of  cancer  is  usually  easy  by  palpation, 
although  there  may  be  difficulty  in  determining  whether  the  growth  is 
primary  or  secondary.  There  need  be  no  hesitation  in  diagnosing  a 
primary  growth  if  there  is  a  large  cancerous  area  in  the  vault  of  the 
vagina  with  an  involvement  of  the  outer  surface  of  the  cervix  con- 
tinuous to  it,  and  no  evidence  of  carcinoma  elsewhere  in  the  pelvis. 

Prognosis. — The  prognosis  is  extremely  bad.  There  are  few  cases 
of  cures,  even  after  the  most  extensive  operation ;  and  these  have  been 
calculated  on  the  three-year  freedom  from  recurrence,  which  is  no  longer 
acceptable  to  cancer  students.  The  case  of  Lequeu,  which  remained 
cured  for  ten  years,  is  unique  in  the  literature.  Since  the  operation  was 
a  partial  removal  of  the  vagina,  we  must  regard  the  cure  as  accidental 
and  due  to  the  low  malignancy  of  the  tumor.  It  is  generally  accepted 
that  a  case  is  hopeless  when  the  glands  are  involved.  There  are  no 
cures  when  the  disease  was  complicated  by  pregnancy. 

SARCOMA  OF  THE  VAGINA 

Sarcoma  of  the  vagina  may  occur  at  any  time  of  life.  The  disease 
is  rare,  although  it  has  been  known  since  1850,  when  Guersant  de- 
scribed the  first  accepted  cases  of  sarcoma  botryoids.  Kaschewarowa- 
Rudwena  made  the  first  extensive  study  of  the  same  type  of  tumor  in 


58  PELVIC   NEOPLASMS 

1872,  the  same  year  in  which  Spiegelberg  reported  the  first  accepted 
tumor  of  vaginal  sarcoma  in  the  adult.  Since  then  a  considerable 
literature  has  gradually  accumulated,  in  which,  however,  there  still 
remains  much  confusion. 

Classification. — All  classifications  which  have  thus  far  been  ad- 
vanced leave  much  to  be  desired.  Histologically,  nearly  all  varieties  of 
sarcoma  have  been  encountered:  myosarcoma,  including  myofibrosar- 
coma  and  rhabdomyosarcoma ;  fibrosarcoma;  and  myxosarcoma,  pre- 
senting as  round-celled,  spindle-celled,  giant-celled,  or  mixed-celled 
growths.  Tumors  of  nearly  identical  histology,  however,  may  vary  so 
tremendously  in  their  clinical  features  that  a  histological  classification 
fails  for  clinical  purposes.  The  converse  also  is  true,  since  tumors  pre- 
senting similar  gross  morphology  may  vary  widely,  both  in  malignancy 
and  in  their  histological  picture. 

Some,  as  Wilms,  Steinthal,  Kolisko,  and  others,  have  claimed  that 
because  sarcoma  is  essentially  a  disease  of  youth,  we  should  distinguish 
clearly  between  vaginal  sarcoma  of  infancy  and  sarcoma  in  the  adult 
vagina.  The  arguments  are  chiefly  based  on  the  histogenesis.  They 
reason  that  sarcoma  in  childhood  develops  from  congenital  anlage — 
from  displaced  embryonal,  non-differentiated  mesodermal  cells;  that 
it  is  in  reality  a  mixed  tumor,  since  it  frequently  suggests  the  teratoma. 
On  the  contrary,  sarcoma  in  the  adult  is  purely  a  sarcoma  and  results 
from  metaplasia  of  connective  tissue  cells.  In  this  way,  they  account 
for  the  presence  of  the  cross-striated  muscle  fibers  in  the  sarcoma  of 
childhood  which  are  not  found  in  those  of  adult  life.  Others,  as  Pick, 
while  not  believing  that  a  distinction  between  sarcoma  of  infancy  and 
adult  life  can  be  made  upon  pathogenic  and  morphologic  grounds, 
agree  that  the  clinical  distinctions  warrant  the  separation.  Conse- 
quently, the  majority  of  authors  present  this  chapter  under  the  head- 
ings of  sarcoma  in  infancy,  and  sarcoma  of  the  adult.  Further  sub- 
division does  not  seem  necessary. 

SARCOMA  IN  INFANCY 

There  are  comparatively  few  recorded  cases.  Veit,  in  1908,  states 
that  there  were  more  than  40.  McFarland,  in  1911,  after  a  critical, 
painstaking  review,  tabulates  44  as  finally  proved.  Of  these,  34  were 
sarcoma  botryoids,  all  in  children  of  five  years  and  under;  10  were  sar- 
comata of  miscellaneous  types,  seen  in  children  under  thirty-one 
months  of  age.  The  list  is  not  large,  since  Himmelstrup  in  1918  could 
find  but  33  primary  racemose  sarcomata.  The  rarity  of  the  disease  is 
well  shown  by  McFarland's  tables,  which  show  that  sarcoma  botryoids 
has  been  reported  on  the  average  of  T  case  every  year  and  eight 
months.  There  has  been  only  i  case  (unreported)  in  our  clinic  at  the 
University  of  California  during  the  last  4,000  cases. 


MALIGNANT  TUMORS  OP  VAGINA  59 

Etiology. — Besides  the  fact  that  the  disease  may  develop  in  intra- 
uterine  life,  nothing  is  actually  known.  Kolisko  and  Hauser  feel  that 
the  etiology  is  best  explained  by  Cohnheim's  theory  of  embryonal  ves- 
tiges, but  many  disagree.  Trauma  does  not  appear  to  be  a  factor. 

Age. — At  least  i  case  has  been  observed  in  a  newborn  child. 
Textbooks  usually  state  that  nearly  all-  cases  develop  during  the  first 
year,  but  this  is  not  confirmed  by  the  literature  from  which  we  obtain 
the  following: 

AGE  INCIDENCE  FOR  CASES  OF  SARCOMA  OF  THE  VAGINA  IN   INFANCY 

First  year 12 

Second   year 14 

Third  year. 12 

Fourth    year 4 

Fifth  year 2 

Some  claim  that  the  disease  may  be  present  at  birth  but  escapes  recog- 
nition because  it  is  hidden  in  the  vagina.  They  urge,  moreover,  that  it 
may  remain  latent  for  a  considerable  length  of  time,  and  not  develop 
symptoms,  until  shortly  before  it  has  started  to  grow  sufficiently  to 
form  a  tumor  mass,  so  large  that  it  can  remain  no  longer  in  the  vagina. 
They  cite  in  support  of  this  view  the  case  of  Demme-Granischer,  in 
which  a  pea-sized  nodule  was  noticed  at  birth  that  did  not  grow  to  any 
extent  until  the  sixth  year. 

Point  of  Origin. — All  agree  that  the  tumor  begins  in  the  submucosa, 
although  there  is  no  agreement  as  to  the  exact  point  of  origin.  Ahl- 
feld,  who  believed  that  all  the  sarcoma  botryoids  are  congenital,  held 
that  they  developed  in  the  papillae  which  are  so  numerous  in  the 
vaginal  wall  of  the  fifth  month  of  intra-uterine  life.  Pfannenstiel,  and 
many  others,  considered  that  they  arise  from  the  peri-endothelial  tis- 
sues of  the  blood  and  lymph  capillaries. 

Location. — The  growth  usually  develops  primarily  on  the  anterior 
wall.  McFarland  gives  the  following  table  showing  the  anatomical 
origin  of  the  34  cases  of  sarcoma  botryoids  vaginae  which  he  collected. 

Vulvovaginal  entrance 2 

Whole  vagina 2 

Anterior  wall 10 

Posterior  wall 4 

Right  wall 2 

Left  wall 4 

Not  stated 10 

34 


6o 


PELVIC  NEOPLASMS 


Appearance  and  Form. — The  tumors  are  essentially  polypoid  and 
usually  arise  from  a  broad  base  as  single  growths.  Occasionally,  single 
tumors  become  ulcerated,  and  slough  spontaneously,  and  are  followed 
by  a  diffuse  infiltration  of  the  whole  vagina.  The  affected  area  in  such 
cases  usually  appears  as  an  infiltrating  mass  of  small  nodules.  These 
cases  are  rare. 

The  typical  form  of  vaginal  .sarcoma  of  infancy  is  usually  described 
as  sarcoma  botryoids,  or  grapelike  sarcoma,  because  the  polyps  sug- 


Dr. 


V 
FIG.  21. — SARCOMA  BOTRYOIDS  IN  CHILD  (Kelly,  Operative  Gynecology). 

gest  numbers  of  small  grapes  or  currants;  or  as  myxosarcoma  (Fig. 
21 ).  As  the  name  implies,  the  growth  is  characterized  by  the  develop- 
ment of  racemose  clusters  of  pedunculated  polyps,  that  are  so  trans- 
lucent they  appear  to  be  vesicles.  The  primary  color  is  pinkish  gray, 
but  the  polyps  are  usually  so  hemorrhagic  that  they  look  dark  red.  At 
the  base  of  the  larger  polyps  are  smaller  ones  in  between  which  the 
larger  growths  project  into  the  vaginal  cavity.  The  surfaces  of  the 
individual  polyps  are  smooth,  since  they  are  covered  by.  vaginal  epi- 


MALIGNANT  TUMORS  OF  VAGINA  61 

thelium.  At  first  sight,  the  early  growths  suggest  a  mass  of  ordinary 
mucous  polyps  which  are  unusually  edematous. 

Method  of  Growth. — The  tumor  first  presents  as  a  small,  rounded, 
broad-based  polyp,  which  soon  becomes  pedunculated  and  edematous. 
Similar  growths  appear  in  close  proximity  and  presently  a  lobulate 
polyp  mass  fills  the  vaginal  canal,  distends  the  vagina,  and  is  shortly 
extruded  beyond  the  vulva. 

The  tumor  grows  by  direct  extension,  and  does  not  give  rise  to 
general  metastases.  It  is  purely  a  local  progressively  extending  tumor. 
As  the  tumor  grows,  its  base  becomes  broader  and  infiltrates  the 
vaginal  wall.  Since  the  majority  of  the  tumors  are  situated  on  the 
anterior  wall,  the  bladder  is  usually  invaded  fairly  early.  Intravesical 
tumors  form  with  the  same  morphological  picture  as  the  primary 
vaginal  tumor.  With  further  extension  of  growth,  the  cervix  and 
uterus  become  infiltrated,  the  parametrium  is  invaded,  and  the  vesical 
ends  of  the  ureters  are  infiltrated,  so  that  hydro-ureter  and  hydro- 
nephrosis  often  result.  Secondarily,  the  vulva  becomes  affected,  and 
the  inguinal,  iliac  and  lumbar  glands  may  become  involved.  Growths 
on  the  peritoneum  were  noted  in  Korner's  case.  On  the  contrary,  the 
growth  does  not  cross  the  rectovaginal  septum,  even  when  the  tumor 
arises  from  the  posterior  vaginal  wall.  Only  in  the  case  of  d'Arcy 
Power  was  the  rectovaginal  septum  infiltrated,  which  Pick  believes 
was  due  to  extension  through  the  blood  vessels. 

The  metastases  are  only  regional,  with  the  exception  of  the  case  of 
Demme  which  had  a  metastasis  in  the  left  ovary  the  size  of  an  orange. 

Histologic  Picture. — The  histological  picture  varies.  All  the  types 
of  sarcoma  are  represented.  In  the  34  sarcoma  botryoids  cases  col- 
lected by  McFarland,  the  histologic  diagnosis  was  made  in  19.  Of 
these,  7  were  mixed-cell,  I  round-cell  growth,  3  spindle-cell,  while  3 
each  were  described  merely  as  myosarcoma  and  fibrosarcoma;  i  was 
termed  myofibrosarcoma,  and  i  myxosarcoma.  The  growth  was  desig- 
nated in  6  of  the  10  vaginal  sarcoma  in  infancy  not  botryoids,  i  each  as 
rhabdomyosarcoma,  myosarcoma,  myxosarcoma,  round-cell  sarcoma, 
perithelioma  and  endothelioma. 

The  free  surfaces  of  the  vegetations  are  covered  at  first  with  the 
normal  vaginal  epithelium  which  usually  presents  ulcerated  areas  in  the 
later  stages  of  the  growth.  Even  in  the  cases  which  present  consider- 
able superficial  necrosis,  the  squamous  vaginal  epithelium  will  be  found 
intact  in  the  folds  at  the  base  of  the  polyps.  As  a  rule,  the  mucosa  is 
infiltrated  with  leukocytes,  which  process  may  extend  to  a  considerable 
depth  into  the  tumor.  The  superficial  margins  of  the  polyps  are  more 
cellular  than  the  core,  where  the  cells  are  widely  separated,  not  only 
from  edema,  but  often  because  of  myxomatous  changes.  The  tumor 
cells  may  be  round,  or  spindle-shaped,  or  both  in  combination  :  giant 
cells  have  frequently  been  described.  Embryonic  striated  muscle 


62  PELVIC  NEOPLASMS 

bands  have  been  seen  in  a  large  number  of  cases.  Piquand  states  that 
they  correspond  to  the  striated  muscle  of  a  three-month  embryo.  The 
secondary  and  metastatic  growths  present  a  similar  picture. 

Symptoms. — Vulvar  pain  and  a  bloodstained  discharge  are  usually 
the  first  symptoms,  although  occasionally  a  polyp  projects  from  the 
vulva  and  gives  the  first  sign  of  the  growth.  Pain  on  urination  soon 
follows,  when  the  bladder  becomes  involved  by  the  growth's  extension, 
or  there  is  cystitis  from  bacterial  invasion.  Although  the  rectum  is  not 
directly  invaded,  there  may  be  difficulty  in  defecation,  possibly  because 
of  the  pressure  the  growth  exerts  in  the  pelvis,  as  well  as  from  the 
general  pelvic  infiltration.  The  patients  are  usually  brought  early  for 
treatment. 

Duration  of  the  Disease. — This  varies  considerably,  yet  is  usually 
only  a  few  months.  There  is  one  case,  however,  that  of  Demme,  in 
which  the  tumor  was  observed  at  birth,  but  death  did  not  follow  until 
the  sixth  year. 

Diagnosis. — The  diagnosis  is  often  difficult,  but  must  be  made 
tentatively  whenever  a  polyp  protrudes  from  the  vulva  or  where  there 
is  a  bloodstained  discharge.  If  we  would  hope  to  cure  we  must  view  all 
suspicious  cases  as  malignant  until  all  other  possibilities  are  excluded, 
just  as  we  do  in  cervical  cancer.  The  literature  fairly  abounds  in 
cases  which  were  proved  to  be  malignant  only  when  the  tumor  had 
been  incited  to  a  tremendously  rapid  growth  by  the  removal  of  a 
polyp  that  was  thought  to  be  benign.  Tissues  should  not  be  removed 
for  microscopic  examination  unless  the  diagnosis  of  malignancy  can 
be  followed  immediately  by  a  radical  operation.  Difficulties  in  making 
a  diagnosis  are  well  shown  by  the  Demme-Granischer  case,  where  only 
a  pea-sized  polyp  protruded  from  the  vulva  of  a  newborn  child,  which 
was  considered  benign  because  clinically  it  remained  unaltered  and 
without  symptoms  for  six  years. 

Direct  inspection  of  the  vagina  is  possible  even  in  the  newborn  child 
with  the  use  of  the  Kelly  cystoscope.  The  vagina  should  be  inspected 
and  the  rectum  palpated  before  any  attempt  is  made  to  obtain  a  speci- 
men for  microscopic  examination. 

Prognosis. — The  prognosis,  as  the  matter  now  stands,  is  death. 
Death  results  from  infectious  processes  ascending  from  the  bladder  or 
uterus  to  cause  pyonephrosis,  peritonitis,  pyemia  or  septicemia. 

Therapy. — A  review  of  the  literature  will  convince  even  the  most 
sanguine  that  no  method  of  therapy  has  proved  of  benefit.  The  only 
case  that  the  literature  records  as  cured  is  the  case  of  Schuchardt 
(credited  by  Powers  and  by  Veit  to  Volkmann — but  in  reality  reported 
by  Fricke.  The  literature  fairly  abounds  in  similar  instances  where 
the  same  case  is  reported  in  a  student's  inaugural  dissertation,  by  a 
pathologist  in  a  monograph,  and  by  the  surgeon  at  a  clinical  meeting). 


MALIGNANT  TUMORS  OF  VAGINA  63 

A  study  of  this  case  convinces  us  that  the  result  was  pure  luck  and  due 
to  the  low  malignancy  of  the  tumor,  since  truly  radical  operations  have 
failed  to  cure  other  growths  of  similar  size.  In  the  case  in  question,  a 
polyp  developed  from  the  posterior  vaginal  wall.  At  the  first  operation 
they  cut  away  with  the  polyp  a  piece  of  the  vagina  the  size  of  a  ten- 
pfennig  piece.  The  growth  recurred.  Six  and  a  half  months  after  the 
first  operation,  the  mass  was  pulled  down  with  forceps  and  the  lower 
half  of  the  vagina  was  removed,  together  with  the  broad-based  tumor. 
Following  this,  the  child  lived  without  a  recurrence  for  ten  years.  The 
most  extensive  resection  is  credited  to  Israel.  Hollander  removed  for 
diagnostic  purposes  a  polyp  the  size  of  a  dove's  egg  which  filled  the 
vagina  of  a  nine-months-old  baby  and  had  given  symptoms  of  blood 
on  the  napkins  for  two  months.  Pick  made  the  diagnosis.  In  spite  of 
a  truly  radical  operation,  in  which  Israel  did  a  parasacral  removal  of  the 
uterus  and  vagina,  the  growth  recurred  in  a  few  months.  There  is,  of 
course,  a  question  whether  a  cure  could  have  been  affected  had  the  diagnosis 
made  by  frozen  sections  at  the  operating  table  been  followed  by  immediate 
removal. 

Theoretically,  radium  should  supplant  operation  in  this  field.  As 
yet  there  are  no  cases  of  five-years  standing  in  which  radium  treatment 
has  been  reported.  X-ray  has  been  tried  without  benefit. 


SARCOMA  OF  THE  ADULT 

Fortunately,  this  is  also  a  rare  disease.  Spiegelberg  described  the 
first  case  in  1872.  In  1899,  Seitz  collected  33  cases.  McFarland,  in 
1911,  collected  67  cases.  Since  then  Tracy,  1912,  added  2  cases  and 
from  time  to  time  other  isolated  cases  have  appeared  in  the  literature. 
Graefe,  in  1912,  reported  the  fourth  case  of  melanotic  vaginal  sarcoma 
of  the  adult. 

Classification. — Two  types  are  noted.  The  most  common  form  is 
definitely  polypoid  and  circumscribed  (Fig.  22).  The  other  type 
appears  as  a  dense  nodular  infiltration.  The  tumor  is  rarely  melanotic. 

Etiology. — The  etiology  is  not  known.  The  theories  which  have 
been  advanced  for  sarcoma  in  general  have  been  suggested  for  sarcoma 
in  this  region.  Few  believe  that  the  Cohnheim  theory  is  applicable 
here,  except  possibly  in  some  of  the  cases  in  the  very  young.  Irritation 
does  not  seem  to  be  a  factor,  otherwise  the  disease  would  be  far  more 
frequent. 

Age. — The  disease  is  essentially  one  of  the  sexually  active  life.  It 
may  occur  in  the  pregnant.  More  than  three-fourths  of  the  recorded 
cases  are  under  forty-five  years,  as  is  shown  by  a  study  of  McFarland's 
tables,  rearranged  to  show  the  disease  by  decades. 


PELVIC  NEOPLASMS 

Total  Cases 

14—20  years  inclusive 9 

21-30      "  7 

31-40       "  J4 

4i-5o      "  ..' 6 

51-60  i 

60  and  over 2  (one  70  years) 

(one  82  years) 


PIG.  22. — VAGINAL  SARCOMA  (redrawn  from  Boldt). 

Appearance  and  Form. — The  circumscribed  type  is  far  the  more 
common,  and  usually  appears  as  a  small,  rounded,  firm  nodule,  the  size 
of  a  bean.  It  is  usually  broad-based,  but  may  have  a  short  pedicle.  It 
may  develop  to  considerable  size.  Jung's  first  case  was  a  fist-sized 
polyp.  In  the  early  growths,  the  surface  is  smooth,  since  it  is  covered 
with  intact  vaginal  epithelium.  The  growth  may  be  lobulated.  Usually 
hard,  it  may  be  soft  and  edematous.  Primarily,  it  has  a  pinkish  gray 
color,  but  more  often  it  is  dark  red,  since  it  is  generally  inflamed, 
although  rarely  ulcerated. 


MALIGNANT  TUMORS  OF  VAGINA  65 

The  infiltrative  type  is  more  rare.  It  usually  occurs  primarily, 
but  sometimes  results  following  spontaneous  necrosis  of  the  small  cir- 
cumscribed type  of  tumor.  This  form  of  growth  is  nearly  always  ulcer- 
ated, and  invariably  hemorrhagic.  It  presents  as  a  mass  of  soft  bossed 
outgrowths  in  the  infiltrated  vascular  vaginal  wall.  Occasionally  it 
encircles  the  vagina,  producing  a  marked  constriction  of  the  lumen. 

Location. — The  tumor  may  develop  in  any  part  of  the  vaginal  sub- 
mucosa,  yet  usually  is  found  in  the  lower  third  of  the  canal.  It  is 
equally  frequent  on  the  anterior  and  posterior  walls.  The  location 
is  well  shown  by  McFarland's  table  which  contained,  however,  10 
cases  of  vaginal  sarcoma  in  infancy  not  of  the  botryoids  type. 

ANATOMICAL  ORIGIN  OF  SARCOMA  VAGINAE  CASES  NOT  INCLUDING 

SARCOMA  BOTRYOIDS 

Vulvovaginal  entrance 2 

Entire  circumference  of  vagina 2 

Anterior  wall 20 

Posterior  wall 19 

Right  wall 2 

Left  wall ' 4 

Vesicovaginal  septum   I 

Rectovaginal  septum    I 

Location  not  stated 17 

68 

Histology. — Histologically,  the  tumors  are  composed  of  round, 
spindle,  or  mixed  round  and  spindle  cells.  The  spindle-celled  form  is 
the  most  common.  The  tumor  may  contain  giant  cells.  There  are 
4  cases  of  melanosarcoma  on  record:  Parona,  Boldt,  Eggel,  Graefe. 
The  soft  tumors  may  show  a  preponderance  of  myxomatous  tissue. 
Often  in  the  vascular  tumors,  the  spindle-shaped  cells  may  be 'traced 
to  a  proliferation  of  the  endothelium  of  lymph  vessels  or  capillaries. 
Some,  as  Gebhard,  have  urged  that  the  endothelioma  be  considered 
apart  from  the  sarcoma. 

The  tumors  are  variously  classified  as  is  shown  in  the  following  list 
from  McFarland's  collected  cases  : 

Spindle-cell  sarcoma • 12 

Round-cell  sarcoma 6 

Mixed-cell  sarcoma   4 

(Giant  cell  included  under  mixed  cell) 

Myosarcoma    2 

Myxosarcoma i 

Fibrosarcoma 2 

Alveolar  spindle  cell i 

Angio  sarcoma 3 


66  PELVIC  NEOPLASMS 

Endothelioma   3 

Melanotic  sarcoma I 

Melanotic  spindle  cell I 

Question  as  to  type 1 1 

Type  not  stated 1 1 

58 

Method  of  Growth. — The  tumor  grows  by  direct  extension  and 
soon  reaches  the  bladder  and  pelvic  connective  tissues.  The  regional 
lymph  glands,  inguinal  and  pelvic,  are  usually  early  invaded,  although 
the  inguinal  glands  appeared  to  be  free  in  both  of  Jung's  cases.  The 
uterus  is  seldom  affected.  The  rectum,  as  in  the  sarcoma  of  the  vagina 
in  infants,  appears  to  escape  invasion  in  the  growths  which  are  primary 
on  the  posterior  wall.  It  was  not  involved  in  Powers'  and  Seitz's  cases, 
although  the  growth  was  extensive,  and  the  rectovaginal  wall  was 
infiltrated.  It  is  usually  stated  that  widespread  dissemination  is  rare, 
yet  there  are  few  autopsy  records  from  which  we  may  confirm  this 
statement.  Metastases  in  the -lungs,  pleura,  ribs,  skin  of  chest,  axillary 
and  jugular  glands  were  found  in  the  combined  cases  of  Spiegelberg, 
Bajandi,  Herzfeld  and  von  Rosthorn. 

Symptoms. — The  symptoms  are  not  characteristic  and  depencj  upon 
the  nature  and  type  of  the  growth,  its  situation,  and  the  extent  of  the 
involvement  of  adjacent  structures.  In  several  cases,  a  "lump"  felt  by 
the  patient  was  the  first  symptom.  A  foul,  bloodstained  discharge, 
backache,  a  feeling  of  weight  in  the  vagina  and  bearing-down  pains, 
dyspareunia,  urinary  tenesmus,  bowel  obstruction  and  anemia  consti- 
tute the  usual  list  of  symptoms. 

Diagnosis. — A  macroscopic  diagnosis  is  often  possible  in  the  cir- 
cumscribed growths  which  exhibit  evidences  of  rapid  growth,  bleed 
easily  and  show  areas  of  ulceration.  Occasionally,  however,  they  may 
be  confused  with  the  fibromyomata,  or  with  a  cyst  which  has  under- 
gone degeneration.  There  should  be  little  difficulty  in  recognizing  the 
malignant  nature  of  the  infiltrating  form,  although  the  differential 
diagnosis  from  carcinoma,  tuberculous,  and  luetic  ulcers  is  not  easy. 
The  final  diagnosis  must  be  made  with  the  miscoscope.  Yet  tissue 
must  not  be  snipped  from  tumors  for  diagnostic  purposes  unless  the 
case  is  ready  for  immediate  operation.  No  one  may  review  the  original 
case  reports  of  the  literature  of  pelvic  cancers,  without  becoming  firmly 
convinced  that  delay  in  operating  following  the  removal  of  tissues  for 
diagnostic  purposes  has  lost  all  chance  of  cure  in  many  cases.  The 
diagnosis  should  be  made  or  confirmed  by  frozen  sections  only  immedi- 
ately preceding  operation. 

Prognosis. — The  prognosis  is  death,  which  comes  usually  from 
sepsis  and  cachexia.  The  disease  runs  an  extremely  short  course  with 


MALIGNANT  TUMORS  OF  VAGINA  67 

an  average  duration  of  ten  and  a  half  months  from  the  first  definite 
symptom  (Seitz,  Williams).  Contrary  to  expectation,  the  course  is 
not  more  rapid  when  the  disease  starts  during  pregnancy.  By  the  time 
the  symptoms  are  pronounced,  the  disease  has  usually  made  much 
headway.  Hence  patients  usually  come  too  late  for  operation. 

Treatment. — Surgery  thus  far  has  proved  a  complete  failure,  since 
recurrence  has  been  almost  immediate  even  in  supposedly  favorable 
cases.  Rubeska's  case  (1896)  of  an  eleven-years  cure  stands  practic- 
ally alone,  since  there  are  no  others  cured  for  the  five-year  period. 
Spiegelberg's  case  was  free  for  four  years. 

Study  of  the  literature  convinces  us  that  there  is  no  hope  of  sur- 
gical cure  unless  a  truly  radical  operation  is  done  and  then  only  on 
favorable  cases.  The  entire  vagina  with  the  uterus  should  be  removed 
in  one  piece  by  perineal  or  better  by  parasacral  dissection. 

Radium  to  us  seems  far  preferable  to  any  known  method  of  treatment 
in  spite  of  the  danger  of  injury  to  both  bladder  and  rectum.  X-ray  has 
been  tried  often  without  success.  There  are  as  yet  no  case  reports  of 
radium  treatment  of  five-years  standing. 

In  the  inoperable  cases,  the  cautery  at  dull  heat  may  do  much  to  secure 
relief  if  radium  is  not  obtainable. 

LITERATURE 

BASSETT.     Treatment  of  Primary  Epithelioma  of  Clitoris.     Rev.  de  Chir. 

1912.     Vol.  47. 
DITTRICK.     Epithelioma  of  Vulva.     Am.  J.   M.   Sc.     N.   S.    1905.      130, 

2:277. 
EDERLE.     Ueber  Klitoriskarzinom.     Zeitschrift  fur  Geburtshulfe.     1919. 

81  :no. 

GRAEFE.    Monatsschr.  f.  Geb.  u.  Gyn.     1912.    35:196. 
HIMMELSTRUP.    Ugesk  f.  Lacgen.    July  4,  1918.    80:1056. 
KLEIN.  Die  soliden  primaren  Geschwtilste  der  Scheide.   Monatsschr.  f.  Geb. 

u.  Gyn.     1898.     7:564. 

MCFARLAND.    Sarcoma  of  Vagina.    Am.  J.  M.  Sc.  N.    S.     1911.    141:570. 
PICK.    Ueber  Sarkome  des  Uterus  und  der  Vagina.     Arch.  f.  Gyn.     1902. 

66:191. 
ROTHSCHILD.     Maligne  Tumoren  der  Vulva.     Inaug.     Diss.     Frankfurt. 

1912. 

SEITZ.     Volkmann's  Klinische  Vortrage.     1899.     No.  280.     4:75. 
STOECKEL.    Ueber  die  Radikalheilung  des  Vulvakarzinoms.    Munch,  med. 

Wchschr.     1910.     57:497. 

STOECKEL.    Wie  lassen  sich  die  Dauerresultate  bei  der  Operation  des  Vul- 
vakarzinoms vergessern?     Zentralbl.  f.  Gyn.     1912.     36:1102. 
TRACY.    Sarcoma  of  the  Vagina.    Am.  J.  Obst.     1912.     66:647. 
VEIT.     Handbuch  der  Gynakologie.     1908.     3,  1:298. 
VEIT.     Handbuch  der  Gynakologie.     1910.     4,  2:724. 


CHAPTER  V 

BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 

Fibroids — Definition  —  Frequency  —  Age  —  Etiology  —  Histogenesis  —  Growth  of  uterine 
fibroids — Classification,  histologically,  anatomically,  clinically — Submucous  fibroids — 
Intramural  fibroids — Subserous  fibroids — Cervical  fibroids — Structure  of  fibroids — 
Histology — Blood  supply — Lymph  supply — Degeneration  of  fibroids — Frequency — 
Benign  degenerations — Atrophy — Hyaline — Calcareous — Edema  and  cyst  formation- 
Infection  and  suppuration — Necrosis  of  fibroids — Red  degeneration — Fatty  degenera- 
tion— Malignant  degenerations,  sarcomatous — Relation  of  uterine  fibroids  to  carci- 
noma— Effect  of  fibroids  on  neighboring  and  distant  organs — Uterus  and  Adnexa — 
Tubes  and  ovaries — Pelvic  organs — Cardiovascular  changes — Kidney  changes — Nerve 
changes  —  Symptoms  —  Hemorrhage —  Leukorrhea  —  Pain  —  Dysmenor  rhea — Pressure 
symptoms — Diagnosis — Bladder  symptoms — Differential  diagnosis — Prognosis. 

FIBROMYOMA  OF  THE  UTERUS 

Definition. — Fibroids  of  the  uterus  are  benign  neoplasms  which 
develop  in  the  wall  of  the  uterus.  They  are  composed  of  smooth 
muscle  and  fibrous  tissue  in  varying  proportions,  and  contain  blood 
vessels,  lymphatics,  and  probably  nerves.  The  relative  proportion  of 
the  fibrous  and  muscle  tissue  differs  'greatly.  In  general,  as  the  tumor 
grows  older,  the  connective  tissues  increase  at  the  expense  of  the 
muscle  cell.  The  tumors  are  rarely  single  and  may  occur  in  consider- 
able numbers  (Fig.  23).  They  are  usually  circumscribed,  but  may  pre- 
sent as  diffuse  growths.  Fibromyomata  are  also  called  fibroids,  myo- 
mata,  leiomyomata,  and  hysteromyomata  levicellular.  Ordinarily,  the 
terms  fibromyomata,  fibroids,  and  myomata  are  used  interchangeably. 

Frequency. — Fibromyomata  are  probably  the  most  common  neo- 
plasm in  the  human  body.  It  is  difficult  to  determine  their  frequency, 
since  they  may  not  present  symptoms  and  may  be  diagnosed  only 
accidentally.  The  majority  of  textbooks  state  that  they  occur  in  20 
per  cent  of  women  over  thirty,  yet  there  are  few  statistics  which  war- 
rant this  figure.  Probably  the  majority  of  texts  quote  from  the  old 
statistics  of  Bayle,  but  to  us  his  statement  is  not  convincing.  Bayle 
says,  in  1813,  "Car  en  faisant  1'ouverture  du  cadavre  de  cent  femmes 
prises  indistinctement  et  agees  de  plus  de  trent  cinque  ans,  il  est  au 
moins  vingt  chez  lesquelles  on  trouve  un  ou  plusiere  de  ces  corps, 
accidentels."  Klob  later  writes  that  they  are  present  in  40  per  cent 
of  all  women  over  fifty.  Cullen  noted  the  presence  of  fibroids  in  148  of 
742  women  twenty  years  or  over  who  were  autopsied  at  the  Johns 

68 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


69 


Hopkins  Hospital  between  1889  and  1906,  or  in  20  per  cent  of  cases. 
Of  the  148  patients,  43  were  white  and  105  were  black.  In  this  series, 
33.7  per  cent  of  all  the  black  women  twenty  years  of  age  or  more 
coming  to  autopsy  had  fibroids  of  varying  size,  while  only  10  per  cent 
of  the  white  patients  presented  these  growths.  Other  autopsy  figures 
give  much  lower  percentage.  In  the  records  of  1860  autopsies  made  at 
St.  Bartholomew's  Hospital  in  London,  Champney  found  fibroids  in 
8  per  cent  of  the  women.  Young  and  Williams  noted  them  in  7^ 
per  cent  of  363  women  under  thirty-five  years  autopsied  at  the  Boston 
City  Hospital.  The  older  autopsy  records  are  of  interest  since,  at  the 


FIG.  23. — PEDUNCULATED  AND  SESSILE  FIBROID. 

time  of  the  following  reports,  operations  for  fibroids  were  most  uncom- 
mon. Pickard,  in  1813,  found  fibroids  in  I  per  cent  of  800  women  at 
autopsy;  Pollack,  in  1852,  found  the  same  growths  in  7  per  cent  of 
583  post  mortem  cases;  Braune,  Chiari,  and  West  each  noted  I  per 
cent.  They  are  usually  said  to  constitute  about  8  per  cent  of  gyne- 
cologic cases.  Haultain  found  them  in  8  per  cent  of  2,230  gyne- 
cological cases  in  the  Edinburgh  Royal  Infirmary.  Herman  reports 
that  71/2  per  cent  of  his  women  patients  over  thirty-five  were  afflicted 
by  the  growths;  Goetze,  8  per  cent  fibroids  in  his  gynecologic  cases  in 
Greisswald;  Doederlein,  8  per  cent  of  cases  in  Tubingen;  while  Essen- 
Moeller,  Kleinwachter,  and  Hofmeier  found  averages  between  4  per 
cent  and  5  per  cent.  Young  and  Williams  found  small  fibroids  recog- 


nizable  only  after  the  abdomen  was  opened  at  operation  in  2^4  per  cent 
of  1,402  cases  in  Boston. 

Age. — Fibroids  may  occur  at  any  period  of  life,  but  are  usually 
found  during  the  latter  part  of  the  reproductive  period.  The  great 
majority  develop  between  the  ages  of  twenty-five  and  forty.  They 
are  rarely  found  in  women  under  twenty-five,  yet  may  occur  before 
puberty.  Pick  and  Anspach  have  found  them  in  newborn  children. 
Sasaki  observed  multiple  fibroids  in  a  child  of  nine  years.  Gusserow 
reported  cases  in  children  of  ten,  fourteen,  and  sixteen,  3  cases  at 
eighteen,  and  8  at  nineteen.  Tillaux  saw  I  in  a  nineteen-year-old  girl 
who  had  been  having  symptoms  for  six  years.  They  are  rare  after  the 
menopause.  In  Cullen's  series  of  1,307  cases,  the  youngest  was  nine- 
teen; 26  were  under  twenty-five  years;  and  44  were  more  than  fifty- 
five  years.  More  cases  were  seen  at  the  fortieth  year  (93)  than  at  any 
other  age. 

Etiology. — Little  is  definitely  known  regarding  the  etiology.  A 
perfect  host  of  theories  has  been  advanced  to  explain  their  origin; 
the  muscle  cells,  connective  tissue  cells,  the  walls  of  the  blood  vessels, 
and  misplaced  embryonic  cells,  all  have  been  credited  with  furnishing 
the  nidus  for  their  growth.  The  factors  which  lead  to  the  develop- 
ment of  the  tumor  are  also  uncertain. 

Numerous  examples  have  been  cited  which  seem  to  show  that  heredity 
plays  some  part  in  their  causation.  Occasionally,  fibroids  are  noted  in  the 
same  family.  Yet  the  majority  of  these  observations  must  be  regarded 
more  as  coincidence  than  as  cause  and  effect,  since  a  growth  which  consti- 
tutes 8  per  cent  of  gynecologic  cases,  or  which  exists  in  from  10  to  20 
per  cent  of  women  past  middle  life,  must  be  found  frequently  in  large 
families. 

Women  with  negro  blood  seem  more  likely  to  have  fibroids  than  Cau- 
casians, suggesting  that  race  may  have  some  bearing  on  the  etiology. 

Many  have  advanced  the  theory  that  ovarian  hormones  are  a  necessary 
factor  for  the  development  of  the  growth.  This  theory  has  not  been  sub- 
stantiated. There  is  no  doubt,  however,  that  menstruation  has  an  im- 
portant bearing  upon  the  development  of  fibroids,  since  the  vast  majority 
present  only  during  sexual  life.  Webster  claims  that  they  do  not  develop 
anew  in  castrated  women  or  after  the  menopause. 

Histogenesis. — The  histogeny  of  these  growths  is  likewise  uncer- 
tain. Few  longer  believe  Virchow's  theory  that  they  develop  from 
uterine  muscle  cells.  Cohnheim's  theory  of  embryonic  rests  has  been 
applied  to  fibroids  and  is  supported  by  many  pathologists.  Many  sur- 
geons recognize  a  similarity  between  adenomata  of  the  thyroid  and 
fibroids  of  the  uterus  and  consider  that  both  develop  from  embryonic 
rests.  Opitz  held  that  fibroids  arise  not  from  muscle  fibers  but  from 
connective  tissue  by  a  process  of  metaplasia,  and  claims  to  have  traced 
the  development  of  small  fibroids  which  started  from  connective  tissue, 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  7.1 

passed  into  muscle  tissue,  and  then  to  microscopic  tumors.  He  based 
his  theory  on  the  fact  that  embryologically  both  the  uterine  muscle 
and  connective  tissue  develop  from  the  same  undifferentiated  process 
of  the  mesenchyme,  and  that  later  in  life  this  property  of  metaplasia 
is  again  assumed  with  the  result  of  the  formation  of  fibroids  from  un- 
differentiated cells.  Roesger  first  directed  attention  to  the  possibility 
that  fibroids  develop  from  the  blood  vessel  wall.  Because  of  the 
absence  of  the  adventitia  in  the  smaller  arteries  of  small  fibroids,  he 
concluded  that  they  must  originate  in  the  muscle  bands  of  the  arterial 
wall.  Gottschalk  thought  that  the  very  tortuous  portions  of  small 
arteries  were  the  site  of  origin,  and  that  the  corkscrew-like  capillary 
arrangement  constituted  the  nucleus  about  which  they  grew.  Klein- 
wachter  thought  he  could  recognize  obliterated  capillaries  in  the  wall 
which  separate  fibroids  from  the  normal  uterine  tissue.  He  also  be- 
lieved that  the  tumor  developed  about  the  blood  vessels.  Pilliet 
thought  that  the  adventitia  gave  rise  to  embryonic  cells  which  devel- 
oped into  the  neoplasm.  Many  others,  however,  have  rejected  all  these 
theories.  Cullen,  after  a  careful  study  of  an  extremely  large  series  of 
fibroids,  could  not  obtain  any  confirmation  for  the  blood-vessel  theory. 

Leguen,  Marien,  and  Gottschalk  believed  that  inflammation  is  a 
necessary  factor  for  the  development  of  the  growth.  Von  Reckling- 
hausen  thought  that  they  arose  from  wolffian  remnants;  others  laid 
their  origin  to  aberrant  miillerian  tissue.  Theilhaber  thought  that 
fibroids  were  closely  connected  with  disturbances  of  metabolism  and 
chronic  uterine  hyperemia. 

There  is  considerable  discussion  as  to  the  factors  which  predispose 
to  the  growth  of  the  tumor.  Sterility  is  about  the  only  cause  which  is 
admitted,  although  this  is  denied  by  many.  Those  who  advocate  this 
theory  state  that  uterine  muscle  is  designed  by  nature  so  that  it  will 
hypertrophy  to  meet  the  needs  of  pregnancy.  In  case  pregnancy  does 
not  occur,  it  may  respond  to  lesser  sexual  stimuli,  and  hypertrophy  in 
a  pathological  manner  with  the  production  of  fibroids.  Yet  the  rela- 
tion of  sterility  and  fibroids  is  a  subject  in  the  greatest  confusion,  and 
statistics  concerning  it  must  be  cautiously  studied.  The  theory  just 
advanced  leaves  unexplained  fibroids  in  children,  and  the  great  num- 
bers of  women  who  have  fibroids  after  having  borne  several  children. 

Growth  of  Uterine  Fibroids. — We  are  ignorant  of  the  factors  which 
are  concerned  with  the  growth  of  the  tumors.  As  a  rule,  they  grow 
slowly  and  steadily,  and  the  more  fibrous  tissue  in  the  tumor,  the 
slower  its  growth.  Consequently,  myomata  should  develop  more 
quickly  than  fibromata,  which  is  not  always  the  case.  There  are  few 
statistics  which  may  be  used  to  show  the  rate  at  which  fibroids  de- 
velop, since  this  requires  long  periods  of  observation,  and  the  very 
great  majority  of  tumors  are  now  removed  shortly  after  diagnosis.  At 
a  time  when  operations  were  not  common,  Schorler  followed  18  cases 


72  PELVIC  NEOPLASMS 

in  Schroeder's  clinic  for  a  long  period.  He  claimed  that  fibroids  grow 
very  slowly;  that  a  tumor  three  months  old  is  not  large  enough  to  be 
recognized  by  a  bimanual  examination ;  that  it  takes  five  years  to  attain 
to  the  size  of  a  man's  fist;  at  the  end  of  13  years,  it  may  be  as  large 
as  an  adult  head.  Kleinwachter,  as  a  result  of  his  study  of  40  cases, 
concluded  that  Schorler  was  dealing  with  tumors  of  unusually  slow 
growth,  since  in  his  experience  they  develop  much  more  rapidly.  This 
coincides  with  our  observations,  since  we  have  frequently  seen  tumors 
attain  considerable  size  in  a  comparatively  few  years.  The  tumors 
develop  rapidly  during  pregnancy,  and  often  decrease  greatly  during 
the  puerperium.  One  case  under  our  observation  shrank  from  the  size 
of  a  fetal  head  at  time  of  labor  to  a  walnut-size  tumor  three  months 
later.  Such  cases  are  not  the  rule,  however.  The  rapid  increase  in 
the  size  of  fibroids  during  pregnancy  is  often  due  to  edema  rather  than 
to  actual  hypertrophy,  although  pure  fibroids  may  occasionally  show 
actual  hypertrophy  of  the  individual  muscle  cells.  Usually  there  is 
marked  decrease  in  size  following  the  menopause,  which  fact  forms 
the  basis  of  expectant  treatment.  Occasionally,  however,  the  reverse 
is  true,  and  tumors  may  grow  rapidly  during  this  period.  Spontaneous 
disappearance  of  a  fibroid  is  rare,  either  in  the  involution  of  the  puer- 
perium or  at  the  menopause.  Only  tumors  composed  chiefly  of  muscle 
or  containing  much  edema  are  likely  to  show  much  shrinkage  in  size. 
These  findings  agree  with  the  results  obtained  in  the  treatment  of 
uterine  fibroma  by  X-ray,  since  the  growth  rarely  disappears  after 
the  ovarian  function  is  destroyed.  The  same  point  has  been  empha- 
sized by  Cullen,  who  found  that  only  one  tumor  in  twelve  disappeared 
when  the  tumor  was  left,  and  only  the  ovaries  were  removed  at  opera- 
tion. There  was,  however,  one  tumor  that  grew  so  much  after  the 
ovaries  were  removed  that  it  finally  had  to  be  taken  out  at  a  subsequent 
operation. 

Sudden  increase  of  size  usually  results  from  edema  from  some  dis- 
turbance of  the  local  circulation.  Especially  is  it  noticed  in  certain 
degenerative  processes.  Fibroids  rarely  vary  during,  menstruation, 
except  in  the  adenomyomata  which  are  then  congested  and  swollen. 

Fibroids  are  usually  small  but  may  attain  tremendous  size.  The 
larger  tumors  are  usually  cystic.  The  largest  tumors  of  which  we  have 
record  are:  Stockard's  case  of  135-pound  tumor  in  a  negress,  and 
Hunter's  case  of  i4O-pound  tumor,  the  patient  after  the  operation 
weighing  ninety-five  pounds. 

Classification. — Fibroids  may  be  classed  from  several  standpoints. 

Histologically,  they  are  grouped  according  to  the  predominant  tissue 
in  their  composition.  Thus,  on  the  one  hand,  we  have  fibroids  which  are 
composed  chiefly  of  fibrous  connective  tissue ;  on  the  other,  myoma  which 
are  chiefly  of  muscle;  properly  speaking,  fibromyomata  lie  in  between  the 
two.  Practically,  however,  this  classification  is  not  observed  by  the  clini- 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  73 

cian,  and  the  terms  "myoma,''  "fibromyoma/'  and  "fibroid"  are  used  inter- 
changeably. The  growths  containing  glandular  tissue  are  termed  adeno- 
myomata. 

Anatomically,  fibroids  may  be  divided  into  corporeal,  cervical,  and  in- 
traligamentary.  The  former  is  the  most  common. 

Clinically,  they  are  classified  according  to  their  position  in  the  uterine 
wall.  Thus  we  have  submucous  fibroids,  interstitial  or  intramural,  and 
subserous  tumors.  The  intramural  growths  are  the  most  common  and 
the  majority  are  said  to  lie  in  the  posterior  wall.  All  fibroids  in  the 
beginning  are  interstitial,  since  they  develop  in  the  uterine  wall.  They 
may  develop,  however,  in  any  part  of  the  wall,  immediately  under  the 
stroma  or  endometrium,  or  in  any  level  in  between.  Thus  they  may 
long  remain  in  the  body  of  the  uterine  wall,  or  may  be  forced  out  early 
toward  the  plane  of  least  resistance.  The  tumors  which  grow  toward 
the  uterine  cavity  finally  become  submucous;  those  which  start  toward 
the  peritoneal  surface  become  subserous  or,  in  case  they  grow  at  a 
uterine  level  which  is  not  covered  by  peritoneum,  as  at  the  uterine 
attachment  of  the  broad  ligament,  they  are  termed  intraligamentous. 
The  tumors  gradually  pass  through  the  stages  in  which  they  are 
entirely  contained  in  the  uterine  body  wall,  come  to  present  on  a  free 
uterine  surface  by  a  broad  base  (sessile),  and  finally  their  body  leaves 
the  uterus  and  becomes  pedunculated.  Very  rarely  submucous,  pe- 
dunculated  growths  are  forced  out  from  the  uterine  cavity  and  break 
away  and  escape  from  the  body.  In  the  same  way,  pedunculated 
growths  on  the  peritoneal  aspect  of  the  uterus  may  become  detached 
from  the  uterus,  as  a  result  of  torsion,  etc. ;  but  since  they  cannot 
leave  the  abdomen,  they  either  lie  free  or  become  bound  up  in  adhe- 
sions which  later  become  vascularized.  These  tumors  are  termed 
parasitic,  since  they  receive  their  blood  supply  from  other  organs  than 
the  uterus.  We  shall  follow  the  clinical  classification  in  our  study. 

Submucous  Fibroids. — Submucous  fibroids  result  from  centrifugal 
development  of  growths  originally  interstitial.  There  may  be  only 
one  nodule,  or  the  cavity  may  be  fairly  studded  with  tumors,  so  that 
it  becomes  dilated  and  distorted  and  the  growths  are  faceted  from 
pressure.  Small  fibroids  a  centimeter  or  two  in  diameter  usually  are 
sessile.  The  larger  tumors  act  as  irritants,  and  the  uterus  strives  to 
expel  them  by  muscular  contraction.  Thus  they  are  forced  out  until 
they  become  pedunculated  and  grow  down  in  the  direction  of  the 
cervical  canal.  They  may  present  at  the  vagina  as  a  fibroid  polyp. 
The  pedicle  is  usually  thin  and  attenuated.  It  may,  however,  be  fairly 
broad.  The  larger  growths  are  pear-shaped,  since  they  are  molded 
by  the  uterine  pressure.  They  vary  in  size  from  a  cherry-stone  to 
that  of  a  six-months  pregnancy.  Polypoid  fibroids  may  present  at  the 
external  os  during  menstruation  and  recede  later,  when  they  are 
termed  intermittent  polyps.  The  growths  may  be  expelled  sponta- 


74 


PELVIC   NEOPLASMS 


neously  as  a  result  of  necrosis  of  their  pedicle,  which  is  a  frequent  inci- 
dent in  pregnancy,  or  following  various  degenerations  of  the  tumor. 
Pedunculated  submucous  fibroids  are  especially  liable  to  gangrene  or 
putrefaction.  They  are  very  important  clinically,  since  they  usually 
lead  to  alarming  hemorrhage.  A  partial  or  complete  inversion  of  the 
uterus  may  follow  the  expulsion  of  the  submucous  fibroid  (Fig.  24), 
since  the  thin  muscular  wall  around  the  base  of  the  tumor  is  likely 
to  become  paralyzed,  and  follow  the  tumor  as  it  prolapses.  The  mucosa 


FIG.  24. — PEDUNCULATED  SUBMUCOUS  FIBROID  WITH  PARTIAL  INVERSION  OF  UTERUS 
(Kelly,  Operative  Gynecology). 

surrounding  the  tumor  is  generally  hypertrophied  and  injected;  over- 
lying the  tumor  itself  it  is  usually  atrophic.  The  blood  supply  is  better 
than  that  of  the  other  types  and,  therefore,  the  tumor  grows  fairly 
rapidly. 

Intramural  Fibroids. — These  growths  remain  localized  in  the  uter- 
ine wall  and  influence  the  size  and  shape  of  the  uterus  to  a  very 
considerable  degree.  A  single  fibroid  may  grow  uniformly  in  all  direc- 
tions and  may  cause  a  symmetrical  enlargement  of  the  uterus  which 
may  readily  be  confounded  with  pregnancy  (Fig.  25).  Usually,  how- 
ever, they  develop  asymmetrically.  The  cavity  is  usually  distorted  and  elon- 
gated, but  the  lining  mucosa  usually  is  not  much  disturbed  by  the 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


75 


smaller  tumors.  The  intramural  fibroids  lie  in  a  thin  capsule  of  loose 
connective  tissue  from  which  they  may  be  shelled  out  with  ease.  The 
only  apparent  connection  between  the  tumor  and  its  host  is  a  number 
of  small  blood  vessels  which  supply  the  tumor  with  its  nourishment. 
The  tumors  are  single  or  multiple;  when  the  latter,  they  grow  at  un- 
equal rates  of  speed. 

Subserous  Fibroids. — These  tumors  arise  in  the  body  of  the  uterus 
and  grow  outward,   and,  taking  the  line  of  least   resistance,   push  their 


FIG.  25. — SOFT  SYMMETRICAL  FIBROID  SIMULATING  Six  MONTHS  PREGNANCY.     Irregu- 
larities in  consistency  of  tumor  suggested  fetal  small  parts. 

way  toward  the  peritoneal  coat  of  the  uterus,  carrying  a  thin  layer 
of  muscle  stratum  before  them.  This  layer  of  muscle  later  may  give 
way  and  finally  disappear,  leaving  the  growth  covered  with  perito- 
neum. At  the  beginning,  they  are  sessile,  with  a  broad  attachment  to 
the  uterus,  and  are  partly  imbedded  in  a  vascular  capsule.  Such  growths 
are  partly  subserous  and  partly  retroperitoneal.  If  growth  continues, 
the  fibroid  becomes  extruded  and  the  uterine  attachment  is  reduced 
to  a  definite  stalk  or  pedicle.  The  length  of  the  pedicle  varies  con- 
siderably as  does  its  thickness;  the  broad  pedicles  contain  muscle, 
connective  tissue,  and  blood  vessels;  the  thinnest  pedicles  contain  only 


PELVIC  NEOPLASMS 

^ssels  covered  with  peritoneum.  The  thickness  of  the  pedicles 
the  character  of  the  growth,  since  they  grow  directly  out- 
irom  a  firm  base,  or  are  deflected  by  the  pressure  of  other 
abdominal  viscera  when  the  pedicles  are  thin.  Pedunculated  subserous 
fibroids  may  acquire  a  great  freedom  of  movement  which  may  lead  to 
strangulation  of  the  growth  with  serious  consequences.  Complete 
separation  from  the  uterus  not  infrequently  occurs,  when  the  nourish- 
ment of  the  tumor  is  obtained  by  adhesions  to  omentum,  etc.,  by  the 
formation  of  a  circulatory  anastomosis.  These  growths  very  rarely  lie 
entirely  free  in  the  abdomen.  Subserous  fibromata  are  usually  mul- 
tiple and  of  small  size,  yet  occasionally  they  attain  considerable  dimen- 
sions. Spencer  Wells  describes  one  that  weighed  thirty-four  pounds. 
The  peritoneal  coat  is  firmly  attached  to  the  tumor.  Subserous  fibro- 
mata may  be  lobulated  or  smooth.  They  frequently  have  large  blood 
vessels  on  their  surface  which  may  rupture  from  trauma,  giving  rise 
to  profuse  intraperitoneai  hemorrhage.  Adhesions  to  surrounding 
structures  are  common,  with  resulting  disturbances  of  function.  When 
the  intestines  become  adherent  to  a  growth  which  has  broken  down 
in  this  manner,  infection  may  pass  through  from  the  bowel. 

Various  complications  arise  from  injury  to  the  pedicle.  Torsion 
is  common,  although  much  less  frequent  than  in  ovarian  tumors.  The 
resulting  changes  vary  according  to  the  number  of  turns  the  tumor 
makes,  the  tightness  of  the  twist,  and  the  suddenness  with  which  tor- 
sion is  accomplished.  Sometimes  the  uterus  itself  is  the  seat  of  the 
torsion,  especially  when  it  has  been  thinned  by  the  traction  caused  by 
the  upward  growth  of  the  tumor  so  that  it  has  become  in  effect  the 
pedicle  of  the  tumor.  Torsion  of  120  degrees  or  more  is  frequently 
noted,  and  Lenander  has  described  a  case  in  which  the  tumor  and 
uterus  were  thus  finally  separated  from  the  cervix. 

In  the  milder  forms,  congestion  and  edema  result  from  the  dis- 
turbance of  the  circulation,  and  the  tumor  may  even  be  distended  with 
blood.  The  arteries  are  less  liable  to  compression  because  of  the  sup- 
port given  by  the  thickness  of  the  wall.  Occasionally  the  blood  ves- 
sels of  the  pedicle  become  thrombosed  in  the  later  stages  of  torsion. 

Cervical  Fibroids. — Cervical  fibroids  are  usually  stated  to  be  rare 
and  to  constitute  only  5  per  cent  of  uterine  fibroids.  Schroeder  and 
Lee  described  them  in  8  per  cent  and  15.5  per  cent  respectively. 
Courty  found  them  in  16  per  cent  of  131  cases  of  fibroids. 

They  arise  most  often  from  the  posterior  cervical  wall  and  may  be 
subvesical,  retroperitoneal  or  intraligamentary,  according  as  they  pro- 
ject under  the  bladder,  under  the  peritoneal  investment  of  the  lower 
uterus,  or  out  into  the  broad  ligament  (Figs.  26,  27).  Haultain  class- 
ifies them  according  to  their  vertical  position  as  supravaginal,  intra- 
vaginal  and  intervaginal.  Like  uterine  fibroids,  they  may  remain  local- 
ized to  the  body  of  the  cervix  when  they  are  termed  interstitial;  or 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


77 


chey  may  extend  to  the  cervical  cavity  when  they  are  submucous.  Sub- 
serous  cervical  fibroids,  strictly  speaking,  do  not  occur,  since  the  cervix 
is  situated  at  some  distance  from  the  peritoneum.  Yet  outgrowths 
from  the  cervix  may  burrow  into  the  subserous  connective  tissue,  when 
they  are  more  or  less  analogous  to  subserous  uterine  fibroids. 

Cervical  fibroids  usually  cause  clinical  symptoms,  varying  according 
to  their  size  and  location.  They  do  not  have  the  same  latitude  of 
growth  as  do  fibroids  of  the  uterine  body,  and  pressure  symptoms  come 


FIG.   26. — CERVICAL  FIBROID.     Note  lengthening  of  cervical  canal,  and  Nabothian  follicles. 

Comparatively  early.  When  the  interstitial  growths  attain  consider- 
able size,  the  body  of  the  uterus  is  carried  upward,  and  finally  comes 
to  ride  upon  the  egg-shaped  tumor  very  much  as  does  the  adrenal  on 
the  kidney.  On  bimanual  examination  the  uterine  body  may  be  con- 
founded with  a  subperitoneal  fibroid.  The  cervical  canal  is  usually 
greatly  altered.  It  may  be  elongated  to  five  or  six  inches  in  length 
and  is  expanded  laterally.  The  external  os  is  changed  in  shape,  and 
may  present  either  as  a  crescent,  or  crack,  or  may  be  completely  opened 
up  by  a  submucous  growth.  The  os  may  be  pulled  high  up  under  the 
symphysis,  or  in  one  of  the  lateral  fornices.  The  tumor  may  block 
the  pelvis  and  completely  obliterate  the  cervical  canal  and  vaginal 


PELVIC   NEOPLASMS 


fornices.  Frequently  the  urethra  is  crowded  downwards;  at  times, 
however,  it  is  pulled  upwards  by  the  displacement  of  the  bladder  wall. 
Urinary  symptoms  are  common  with  this  tumor. 

Submucous  cervical  fibroids  may  remain  sessile,  or  may  become 
pedunculated  and  appear  as  myomatous  polypi  at  the  external  os. 
These  latter  may  become  necrotic  and  present  as  a  sloughing  mass  in 
the  vagina.  The  expulsion  of  the  polyp  through  the  external  os  may 


FIG.  27. — CERVICAL  P'IBROID.     Sagittal  section  of  Fig.  26. 

be  accompanied  by  painful  contractions.    The  tumors  do  not,  as  a  rule, 
attain  a  large  size. 

Fibroids  which  arise  from  the  superficial  muscle  tissue  of  the  cervix 
and  grow  outward  into  the  surrounding  cellular  tissue  are  uncommon. 
They  may  grow  to  a  considerable  size  and  burrow  between  the  broad 
ligament,  when  they  are  of  clinical  significance,  both  on  account  of 
their  displacing  the  ureters  and  uterine  vessels  and  because  their  re- 
moval may  be  attended  with  unusual  difficulty.  When  the  growth 
becomes  localized  on  the  posterior  wall,  the  pouch  of  Douglas  is  dis- 
torted and  the  sigmoid  and  rectum  are  usually  elevated.  When  the 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  79 

growth  is  situated  on  the  anterior  vaginal  wall,  the  uterovesical  peri- 
toneum and  bladder  are  raised. 

Cervical  fibroids  are  said  to  grow  more  rapidly  than  uterine  fibroids 
on  account  of  their  proximity  to  the  uterine  vessels.  Alteration  of 
menstruation  is  not  common  unless  the  uterus  is  enlarged. 

Structure  of  Uterine  Fibromyoma. — Fibroids  are  of  the  same  struc- 
ture as  the  uterine  wall,  namely,  muscle  and  connective  tissue.  The  muscle 
is  arranged  in  longitudinal  and  transverse  bundles  bound  together 
by  the  connective  tissue.  The  bundles  are  not  arranged  in  regular 
order.  In  the  smaller  tumors,  they  present  as  irregular  interlacing 
masses  of  unequal  size,  while  in  the  larger  growths  they  are  arranged 
in  whorls.  The  blood  vessels  are  comparatively  few,  although  very 
rarely  one  finds  a  fibroid  containing  many  large  dilated  blood  sinuses, 
a  true  telangiectatic  fibroid.  Surrounding  the  whole  tumor  is  a  zone 
of  connective  tissue  which  is  arranged  as  a  capsule,  and  which  sharply 
separates  it  from  the  uterine  musculature.  The  capsule  is  pierced  by 
the  small  nutrient  blood  vessels  which  run  from  the  uterine  muscula- 
ture into  the  center  of  the  whorls,  and  appear  to  the  naked  eye  as  the 
only  connective  bands  between  the  uterus  and  the  tumor. 

The  appearance  of  the  uterine  musculature  varies  considerably 
according  to  the  location  of  the  tumor.  The  larger  intramural  growths 
are  covered  with  hypertrophied  muscle  cells  which  resemble  those  in 
pregnancy;  while  surmounting  the  pedunculated  types,  which  have 
escaped  from  the  body  of  the  uterus,  the  uterine  muscle  may  be  so 
thin  and  filmy  that  it  is  not  recognizable.  On  section,  the  fibroids  give 
a  sense  of  almost  cartilaginous  hardness,  and  the  peripheries  of  the 
mass  retract  so  that  the  cut  surface  is  bulging.  The  surface  presents 
a  dull  white,  glistening  structure,  broken  by  darker  areas  which  con- 
stitute the  outlines  of  definite  whorls.  The  capsule  retracts  with  the 
margins  of  the  tumor  and  presents  in  contrast  dark  red  in  color,  from 
the  blood  which  has  escaped  in  its  meshes. 

Histology. — The  smallest  fibroids  are  composed  exclusively  of 
smooth  muscle  cells;  when  they  obtain  a  diameter  of  i  centimeter, 
fibrous  tissue  can  be  seen.  Microscopically,  fibroids  have  no  definite 
capsule ;  and  the  identity  of  the  new  growth  can  be  made  out  by  the 
condensation  of  the  muscle  cells  and  their  nuclei,  which  stain  deeper 
than  the  surrounding  connective  tissue  elements.  The  muscle  cells  are 
spindle-shaped  with  long,  narrow  nuclei;  on  transverse  section  the 
central  round  nucleus  is  surrounded  by  a  spherical  mass  of  proto- 
plasm. Mallory,  in  appropriately  stained  material,  was  able  to  demon- 
strate neuroglia,  myoglia  and  fibroglia  in  the  various  tumors.  Speak- 
ing of  myoglia,  he  says  that  "while  in  general  the  smooth  muscle  cells 
closely  resemble  those  found  in  normal  tissue,  they  may  vary  consider- 
ably from  the  normal  type;  the  cells  may  be  long  and  thin  and  the 
nuclei  the  slenderest  of  rods;  in  other  cases  the  cells  are  short  and 


8o  PELVIC  NEOPLASMS 

thick  with  short  oval  nuclei."  The  variation  in  shape  depends  upon 
the  rapidity  of  growth  of  the  tumors.  The  slowest  growing  fibers  are 
the  most  slender.  As  the  fibroid  grows,  it  usually  acquires  a  capsule, 
that  is,  becomes  more  and  more  distinct  from  the  muscle  tissues  of 
the  uterine  wall,  and  comes  to  lie  in  a  loose  cellular  connective  tissue 
bed,  which  is  characterized  by  its  rich  blood  and  lymph  supply.  From 
such  minute  origin,  fibroids  may  develop  even  to  the  enormous  size 
of  Hunter's  i4O-pound  tumor. 

Blood  Supply. — Sampson  in  1912  studied  the  blood  supply  of  one 
hundred  fibromatous  uteri  injected  immediately  after  operation  with 
substances  impervious  to  the  X-ray.  He  believes  that  the  nutrient 
arteries  of  the  tumors  spring  from  radial  or  peripheral  branches  of  the 
uterine  arcuate  arteries.  They  pierce  the  capsule  of  the  tumor,  and 
immediately  divide,  into  either  a  diffuse  proliferation  which ,  penetrates 
the  entire  tumor,  or  into  a  series  of  arterial  trees.  There  are  usually 
only  one  or  two  chief  nutrient  vessels,  although  in  the  larger  growths 
there  is  a  secondary  nutrient  system.  The  latter  consists  of  an  anasto- 
mosis of  a  number  of  arteries  in  the  uterus  surrounding  the  tumor, 
and  of  similar  vessels  in  the  periphery  of  the  fibroid.  The  nutrient 
artery  is  the  main  supply,  and  follows  the  tumor  as  it  moves  in  the 
uterine  wall.  The  secondary  system  may  be  temporary,  or  a  secondary 
development,  resembling  the  blood  supply  which  springs  from  vascu- 
larized  adhesions  about  the  surface  of  subserous  pedunculated  growths. 

The  investigator  was  not  able  to  demonstrate  the  venous  system. 

Lymph  Supply  of  Fibroids. — Polano,  in  1913,  studied  the  lymph 
supply  in  sixteen  fibroids  similarly  injected  with  a  solution  of  camphor 
and  coloring  matter  in  ether.  He  showed  that  the  anatomical  rela- 
tion of  blood  and  lymph  is  very  intimate,  although  there  is  no  definite 
perivascular  lymphatic  arrangement.  The  lymphatic  supply  differs  in 
single  and  multiple  growths.  The  one  seen  in  single  unicentric  nodules 
shows  a  broad  pedicle,  uniting  the  tumor  and  surrounding  tissue, 
through  which  pass  a  number  of  lymph  channels. 

The  other  type  is  seen  in  small  conglomerate  nodules,  which  have 
a  number  of  such  broad  connective  tissue  bridges,  at  various  points 
between  the  tumor  and  the  capsule,  containing  numerous  lymph 
channels. 

In  addition,  there  is,  in  both  types,  a  canal  system  in  the  fine  spider- 
web  type  of  connective  tissue  that  unites  the  tumor  and  the  entire 
length  of  the  capsule. 

Degeneration  of  Fibroids. — There  is  no  tumor  which  may  be  asso- 
ciated with  a  greater  variety  of  pathological  processes  than  a  fibroid. 
Situated  in  an  organ  which  undergoes  so  many  changes  in  size  and  in 
physiological  activity,  which  becomes  functionally  inert  long  before 
senile  changes  appear  elsewhere  in  the  body,  and  which  at  the  time 
of  atrophy  is  subject  to  a  variety  of  lesions,  the  growth  is  under  many 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


81 


influences,  and  may  undergo  almost  any  form  of  degeneration,  and 
also  produce  effects  on  neighboring  or  distant  organs. 

Thorough  and  careful  examination  of  fibroids  usually  shows  some 
form  of  degeneration.  Largely  owing  to  the  disproportion  of  the  size 
of  the  fibroids  and  its  blood  supply,  the  tumors  are  especially  liable 
to  degenerative  alterations  from  comparatively  slight  changes  in  circu- 
lation. These  degenerations  may  be  divided  broadly  into  benign  and 
malignant.  Many  of  the  benign  changes  are  various  stages  in  the  same 
general  pathological  process. 

FREQUENCY  OF. — In  attempting  to  form  an  estimate  as  to  the  frequency 
of  degeneration,  the  following  figures  are  of  interest: 

DEGENERATION 


Frequency  of 

0, 

Uterine  fibroids 

Degeneration 

Webster  

2IO 

C2 

Noble  

337 

62 

Scharlieb  

IOO 

26 

Cullingsworth  .  .                                 

IOO 

C2 

Noble,  in  collecting  2,247  cases,   found  the  following  proportions  of 
degeneration : 


Hyaline    

72 

-2      I 

Hyaline  with  calcareous  infiltration  

8 

O.  1 

Calcareous  

30 

I  .  7 

Myxomatous  

80 

-i  .A 

Cystic  

58 

2  .  =; 

Hemorrhagic  ...     .        

17 

O    ^7 

Necrosis  ....        

IIQ 

4.  7 

Fatty  degeneration                                      

7 

O    2=C 

Edema  .                                                 

17 

O    74. 

Sarcoma  ....               

34 

I    A 

Carcinoma  corpores  

42 

1.8 

Carcinoma  cervix  ...                         

16 

O    7 

Deaver  as  the  result  of  analysis  of  three  hundred  and  forty-five  con- 
secutive operations  for  fibroids  concludes  10  per  cent  of  the  cases  requiring 
operative  treatment  are  having  symptoms  which  are  largely  the  result  of 
benign  degeneration. 

BENIGN  DEGENERATIONS. — Benign  degenerations  are  due  to  many 
causes,  among  the  most  common  of  which  are  emboli  in  the  afferent  artery, 
hemorrhage  from  trauma  or  twisted  pedicle,  and  alteration  in  the  blood 
supply  incident  to  menstruation,  pregnancy,  puerperium  and  the  menopause ; 


82  PELVIC  NEOPLASMS 

more  rarely  dislocation  of  the  tumor  or  injury  to  the  growth  during  labor 
may  initiate  the  process. 

Under  the  heading  of  benign  degenerations,  we  may  list  atrophy,  hya- 
line degenerations,  calcareous  changes,  edema,  cystic  and  myxomatous  de- 
generations, the  various  necroses  and  consequences  of  inflammation.  While 
these  are  benign  degenerations  in  contrast  to  the  malignant  changes,  they 
may  at  the  same  time  cause  symptoms  of  alarming  character  and  may 
actually  cause  death. 

Atrophy. — With  the  cessation  of  the  menstrual  function  and  the  dimi- 
nution of  nourishment  which  follows  the  physiological  involution  of  the 
genital  organs  at  the  menopause,  fibroids  frequently  undergo  spontaneous 
atrophy  and  diminution  in  size.  Marked  atrophy  frequently  ensues  as  the 
result  of  bilateral  oophorectomy,  an  operation  which  was  frequently  per- 
formed in  the  early  days  of  abdominal  surgery  when  the  mortality  for 
hysterectomy  was  in  the  neighborhood  of  25  per  cent.  Lawson  Tait,  in 
1872,  first  advocated  it  and  showed  its  feasibility.  Atrophy  may  come  about 
during  the  puerperium.  X-ray  and  radium  may  also  produce  sclerotic 
changes.  As  a  result  of  atrophy,  the  tumor  cells  are  replaced  by  new  fibrous 
.tissue  and  frequently  there  is  a  marked  overgrowth  of  connective  tissue  so 
that  the  nutrient  vessels  are  constricted.  The  tumor,  as  a  result  of  the 
fibrosis,  becomes  hard  and  indurated  in  character.  These  changes  are  most 
common  in  pedunculated  subperitoneal  growths.  Atrophy  of  fibroids  does 
not  invariably  occur  with  the  onset  of  the  menopause,  nor  do  X-rays  or 
radium  always  produce  permanent  atrophy. 

Hyaline  Degeneration. — This  is  the  most  frequent  degeneration 
found  in  fibroids,  and  is  the  first  change  to  occur  as  the  result  of  mal- 
nutrition. In  3.5  per  cent  of  Noble's  collected  cases  and  in  n  per  cent 
of  Deaver's,  there  were  more  or  less  extensive  areas.  Practically  all  tumors, 
whatever  the  size  or  situation,  show  this  change  in  varying  degrees,  either 
histologically  or  grossly.  When  the  process  is  very  extensive,  the  center 
is  likely  to  break  down  and  become  necrotic;  even  a  large  cystic  cavity 
with  irregular,  softened  walls  may  result  (see  cystic  changes).  The 
distribution  of  the  hyalin  is  variable.  Frequently  the  fibrous  tissue  between 
the  muscle  fibers  is  first  attacked  and  the  muscle  bundles  are  preserved 
intact.  When  the  muscle  bundles  become  involved,  the  cells  are  swollen  and 
their  outlines  are  indistinct  or  lost,  so  that  the  protoplasm  seems  to  have 
fused.  The  nuclei  are  fragmented  and  in  some  instances  have  completely 
disappeared.  They  are  more  resistant  than  the  cytoplasm,  however,  and  may 
remain  as  the  last  evidence  of  the  original  cell  structure.  Infrequently 
the  hyaline  degeneration  appears  to  begin  around  the  blood  vessels,  and 
thence  spread  to  neighboring  structures.  Usually,  however,  blood  vessels 
are  found  lying  in  homogeneously  staining  areas  where  degeneration  has 
completely  altered  the  structure  of  the  surrounding  tissues.  Hyaline  areas 
are  almost  devoid  of  cell  structures. 

Macroscopically.  hyaline  areas  present  a  yellowish  white  appearance, 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  83 

not  unlike  areas  of  fat.  The  color  is  due  to  the  blood  alteration  and  old 
blood  pigment  from  hemorrhage.  The  areas  may  be  sharply  circumscribed, 
and  may  occur  en  masse  or  be  scattered  throughout  the  growth.  The 
change  may  be  limited  to  one  nodule,  or  may  present  simultaneously  in  sev- 
eral fibroids.  On  palpation,  the  tumor  may  be  firm  and  may  differ  in  no 
way  from  ordinary  fibroids.  Others  are  soft  and  succulent  and  give  the 
suggestion  of  lipomata. 

Hyaline  degeneration  is  of  no  clinical  significance  unless  the  retro- 
gressive process  goes  on  to  liquefaction  or  cyst  formation.  Such  an  occur- 
rence is  usually  marked  by  a  rapid  enlargement  of  the  tumor,  and  aug- 
mentation of  the  existing  symptoms.  Sarcomatous  alteration  may  originate 
in  the  areas  of  hyaline  changes.  The  cells  which  resist  the  hyaline  altera- 
tion lie  free  in  the  hyaline  or  serous  fluid  and  appear  occasionally  to  take 
on  active  development. 

Calcareous  Degeneration. — Calcareous  deposits  are  found  usually 
in  atrophic  and  sclerotic  areas  of  tumors  which  have  undergone  a  pro- 
found disturbance  in  their  circulation.  They  cannot  be  laid  down  in 
living  tissues  but  are  found  in  cells  that  are  dead  or  which  have  suf- 
fered serious  injury.  Litten,  in  1879,  proved  that  lime  salts  were 
deposited  in  the  kidneys  of  rabbits  within  a  few  hours  after  the  renal 
vessels  were  tied. 

Calcification  frequently  occurs  in  fibroids  during  the  climacteric, 
probably  as  a  result  of  the  circulatory  changes  and  the  atrophy  which 
ensues  at  that  time.  It  is  commonly  found  in  subserous  pedunculated 
growths  which  have  become  detached  as  a  result  of  torsion,  or  in  the 
tumors  which  hang  by  a  narrow  pedicle.  It  may  occur  in  degenerated 
areas  of  interstitial  growths,  which  may  have  been  moved  about  by  the 
changes  coincident  with  pregnancy.  It  rarely  occurs  in  submucous 
growths,  probably  because  they  rarely  survive  in  loco  profound  dis- 
turbances of  circulation.  The  deposits  consist  of  phosphates  and  car- 
bonates of  lime  which  infiltrates  the  degenerated  areas  of  the  tumor. 
The  mass  grows  in  size,  forms  concentric  plaques,  and  often  unites  with 
neighboring  infiltrated  areas  to  form  definite  calcareous  nodules. 
Occasionally,  the  whole  tumor  becomes  infiltrated  with  the  granular 
calcareous  material,  although  rarely  does  it  become  completely  cal- 
cified. Pedunculated  tumors  which  have  undergone  more  or  less  com- 
plete calcification  may  be  thrown  off  into  the  abdomen  or  the  uterine 
cavity.  They  are  known  as  "womb  stones."  The  periphery  of  the 
tumor  often  presents  many  areas  of  calcification.  If  they  coalesce, 
they  may  completely  occlude  the  blood  supply  of  the  tumor  and  cause 
necrosis  of  the  central  portions.  Histologically,  the  concentric  cal- 
careous plaques  present  a  characteristic  picture  since  they  are  intensely 
colored  by  the  nuclear  stain.  In  the  earlier  stages,  they  are  seen  as 
fine  granules  in  the  fibrous  tissue  and  muscle  cells,  which  have  been 
partially  or  completely  deprived  of  their  blood  supply. 


84  PELVIC   NEOPLASMS 

The  chemistry  of  the  process  was  shown  by  Klatz  in  1905.  He 
believes  that  fatty  changes  in  the  degenerated  areas  precede  the  de- 
posits of  calcium  salt.  The  fatty  changes  are  followed  in  time  by  the 
appearance  of  soap  or  a  soapy  substance  which  unites  with  the  albu- 
mins of  the  degenerating  cell  to  form  soap  albumin.  Calcium  from  the 
blood  unites  with  the  soap  albumin  to  form  insoluble  calcium  curds 
or  double  calcium  soap.  The  latter,  by  the  action  of  substances,  in 
the  body  fluid  containing  carbonic  or  phosphoric  acids,  are  then  decom- 
posed into  phosphates  or  carbonate  of  lime,  and  remain  as  insoluble 
deposits  in  the  tissues. 

Calcified  fibroids  may  cause  much  trouble  even  after  the  meno- 
pause. Louis,  Noble,  Henning  and  others  have  collected  cases  which 
developed  pressure  symptoms,  some  of  them  blocking  the  ureters  and 
causing  death  by  uremia,  creating  fistulae  to  the  bladder,  causing  tor- 
sion and  hemorrhage  into  the  peritoneal  cavity.  Piquand  analyzed  81 
cases  of  calcified  fibroids  and  found  the  following  complications: 

29  cases  caused  compression  on  neighboring  structures. 
15  cases  caused  metrorrhagia. 
18  cases  caused  suppuration. 

Of  26  deaths  not  following  operation 

5  resulted   from   peritonitis. 

3  resulted  from  intestinal  obstruction. 

2  resulted  from  changes  following  retention  of  urine. 

i   resulted  from  hemorrhage. 

7  resulted  from  anemia  and  cachexia  from  suppuration. 

i   resulted  from  rupture  bladder. 

6  resulted  from   cancer  of  uterine  in  conjunction  with  calci- 

fied myoma, 
i   resulted  from  torsion  of  uterus. 

Edema  and  Cystic  Degeneration. — These  processes  usually  affect 
subserous  tumors  of  large  size.  They  are  rarely  found  in  submucous  forms 
and  very  rarely  in  the  interstitial  types.  Piquand  states  that  they  are  seen 
most  often  in  the  larger  single  growths  (Fig.  28). 

Edema  usually  results  from  interference  with  the  return  circulation  of 
the  tumor  so  that  there  is  a  passive  congestion.  The  tumor  is  swollen, 
smooth,  and  rounded,  and  looks  congested.  The  surface  is  reddish  and 
contains  many  large,  branching,  dilated  blood  vessels.  The  tumor  feels 
soft  and  sometimes  fluctuant.  The  edema  may  be  local  or  may  extend 
throughout  the  whole  tumor.  Tn  the  early  stages,  the  growth  is  soft  and 
exudes  serous  fluid  from  cut  surfaces.  In  the  more  advanced  forms,  one 
sees  a  number  of  homogeneous  soft  areas  which  are  translucent.  A  thin, 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


watery  lymph  exudes  from  the  cut  sections.    Small  cavity  formations  may 
be  seen  on  close  inspection  (Fig.  29). 

Cystic  degeneration  usually  follows  extensive  hyaline  degenerations.  It 
results  from  the  liquefaction  of  the  hyaline  areas.  The  resulting  cavities 
are  not  lined  with  endothelium  but  by  hyaline  tissues  which  have  not  yet 
undergone  liquefaction.  The  cavities  grow  by  the  breaking  down  of  tra- 
beculae  which  separates  neighboring  cavities,  and  by  the  amalgamation  of 
small  cysts.  Cystic  formation  may  occur  in  small  areas,  or  may  involve  the 
whole  tumor  simultaneously.  The  small  cysts  which  form  from  the  break- 
ing down  of  trabeculated  areas  of  hyaline  degeneration  are  far  more  com- 


FIG.  28. — LARGE  SUBPERITONEAL  FIBROID  WITH  MARKED  CYSTIC  DEGENERATION. 

mon  than  the  massive  cysts  which  have  involved  the  entire  tumor.  The 
color  of  the  cysts  ranges  from  yellow  to  brownish  green,  or  blood  color,  and 
is  due  to  blood  pigments  which  have  escaped  from  thrombosed  blood  ves- 
sels. There  is  no  other  suggestion  of  blood  in  the  cyst  contents  save  occa- 
sional streaks,  and  the  fluid  contains  neither  leukocytes  nor  fibrine  ferment, 
nor  does  it  coagulate  on  standing. 

The  last  stages  of  liquefaction  are  frequently  termed  myxomatous,  since 
they  give  this  appearance  to  the  naked  eye.  It  rarely  proves  to  be  true 
myxoma,  however,  a  point  emphasized  by  Meslay  and  Heyenne. 

Cystic  degeneration  does  not  always  follow  a  hyaline  change.  It  may 
come  on  after  necrobiosis  of  small  or  large  areas.  Cystic  spaces  lined  with 
endothelium  occur  in  lymphangiectic  and  telangiectic  tumors,  which  are  only 


86 


PELVIC  NEOPLASMS 


blood  and  lymph  spaces  dilated  to  varying  degrees.  This  type  of  tumor 
frequently  changes  in  size  from  time  to  time,  and  the  angiomatous  form 
may  pulsate  synchronously  with  the  heart  beat.  Cystic  degeneration  may 
also  occur  as  the  result  of  radium  treatment.  The  microscopic  findings  are 
fairly  constant.  In  the  earlier  stages,  the  blood  vessels  are  dilated,  and  the 
tissue  cells  are  swollen.  The  cells  do  not  stain  readily  and  the  protoplasm 


FIG.  29. — SOFT  FIBROID  WITH  CYSTIC  DEGENERATION. 

is  granular.  Later,  the  degeneration  has  progressed  so  that  there  is  left 
only  a  few  cellular  fibers,  which  are  separated  by  the  serous  exudate,  with- 
out trace  of  nuclei.  This  type  resembles  myxoma. 

INFECTION  AND  SUPPURATION. — Tumors  of  low  vitality  may  readily 
become  infected  in  case  they  are  already  the  seat  of  other  degenerative 
processes,  and  especially  if  the  uterus  has  undergone  some  profound  dis- 
turbance of  the  circulation,  which  in  turn  reacts  upon  the  tumor.  The 
infection  may  come  from  one  or  more  sources,  and  may  readily  progress  to 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


suppuration.  Usually  it  proceeds  upward  through  the  lower  genital  tract, 
and  into  the  uterine  cavity.  Submucous  tumors  are  most  apt  to  become 
infected  after  abortion  or  infectious  processes  in  the  puerperium  (Fig.  30') 
The  uterine  circulation  at  this  time  is  undergoing  the  changes  characteristic 
of  involution,  which  undoubtedly  tend  to  favor  the  progress  of  bacterial 
invasion.  The  same  changes  are  noted  frequently  after  curettage  or  other 
intra-uterine  manipulations,  in  which  a  portal  of  entry  is  afforded  by  the 
injury  to  the  endometrium  or  by  partial  dislodgment  of  the  tumor.  Some 
claim  that  the  continued  use  of  ergot  tends  to  increase  the  susceptibility  to 


FIG.  30. — MULTIPLE  FIBROIDS.     Necrotic  submucous  fibroid    expelled  after  abortion. 

infection  and,  for  this  reason,  they  have  done  much  to  discourage  the  routine 
treatment  of  submucous  tumors  by  ergot  preparations.  Many  instances  have 
been  recorded  in  which  the  trauma  attending  intra-uterine  electrical  treat- 
ments was  responsible  for  the  infection.  Small  intramural  tumors  may 
readily  become  infected  shortly  after  they  have  become  loosened  from  their 
bed  by  the  involution  following  pregnancy.  We  have  seen  several  cases  in 
which  suppurating  fibroids  have  been  passed  in  the  second  week  of  a  febrile 
puerperium.  *  All  of  these  cases  were  known  to  have  many  small  uterine 
fibroids  during  the  pregnancy.  Cullen  reports  a  case  in  which  tubercle 
bacilli  were  found  in  the  necrotic  center  of  an  intramural  fibroid.  Infective 
agents  find  access  easy  to  small  areas  of  hyaline  or  cystic  degeneration  in 


88  PELVIC   NEOPLASMS 

intramural  fibroids,  when  the  uterine  cavity  is  infected  and  the  fibroid 
impinges  upon  the  endometrium. 

Subserous  fibroids  may  become  infected  when  they  become  involved  in 
adhesions  with  pus  tubes,  ovarian  abscesses  or  other  pelvic  inflammatory 
processes.  Areas  of  former  degenerations,  and  profound  disturbances 
of  the  local  circulation  are  necessary  prerequisites  for  serious  infection  of 
the  tumor.  Occasionally  the  infection  passes  from  the  bowel  to  the  tumor  in 
such  cases  as  are  involved  in  inflammatory  adhesions.  The  appendix  is  the 
chief  offender,  after  which  comes  the  sigmoid  and  the  small  bowel  in  order 
of  frequency. 

Intraligamentary  tumors  may  become  infected  by  extension  of  infection 
from  a  tuboovarian  abscess  which  is  also  adherent  to  the  rectum.  The 
infection  may  remain  localized  or  may  become  general.  If  the  process 
becomes  widespread,  the  symptoms  undergo  a  sudden  change  with  the 
advent  of  suppuration. 

Various  pictures  may  present  with  infected  fibroids.  The  local  infection 
may  be  limited  to  the  interior  of  the  tumor  or  may  break  through  the  cap- 
sule, so  that  the  infection  extends  about  it — between  it  and  the  matrix  of  the 
tumor.  As  a  final  result,  the  tumor  may  be  liberated  from  its  site  and 
expelled  from  the  uterus.  Suppurating  tumors  writhin  the  abdomen  are 
usually  walled  about  with  omentum  and  adherent  bowel.  They  may  be 
expelled  into  the  bladder  or  bowel,  yet  more  commonly  slough  away  and 
are  expelled  through  the  uterine  cavity. 

Pain,  lancinating  in  character,  is  noted.  There  are  chills  and  fever. 
The  patient  may  have  a  sallow  color  and  anemia  from  septic  absorption. 
Kidney  damage,  as  showrn  by  albumin  and  casts,  may  be  present.  If  the 
suppurating  fibroid  opens  into  the  uterine  cavity,  there  is  a  profuse,  foul- 
smelling,  vaginal  discharge.  Suppurating  fibroids  may  slough  and  be 
expelled  through  the  uterine  cavity,  into  the  bladder,  bowel,  or  peritoneal 
cavity.  The  advent  of  this  complication  greatly  increases  the  risk  if 
operative  treatment  is  necessary,  particularly  if  the  patient's  resistance  has 
been  lowered  by  a  long-continued,  suppurative  process. 

NECROSIS  OF  FIBROIDS. — Necrosis  is  frequently  present  in  small  or  large 
areas.  It  is  usually  preceded  by  hyaline  degeneration  as  the  initial  change 
indicative  of  faulty  nutrition.  Necrosis  is  a  terminal  condition.  It  usually 
affects  a  limited  part  of  the  tumor  when  it  does  not  necessarily  give  rise  to 
symptoms.  Clinical  manifestations  invariably  follow  a  widespread  necrosis. 

Necrosis  may  occur  in  any  type  of  tumor.  Christopher  Martin  found 
it  in  4  per  cent  of  his  series  of  fibroids;  Noble  in  5  per  cent  of  119  cases; 
Tracy  observed  it  in  5  per  cent.  Necrosis  often  follows  torsion  of  a  pedun- 
culated  fibroid  and  is  associated  with  local  hemorrhagic  or  anemic  condi- 
tions. It  occurs  in  isolated  foci  in  the  midst  of  apparently  normal  fibroid 
tissues.  The  central  part  of  the  tumor  is  usually  affected  because  it  is 
furthest  from  the  blood  supply. 

The  necrotic  areas  are  likelv  to  become  infected  in  submucous  tumors 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  89 

during  the  puerperium.  Gangrene  and  sloughing  may  result  with  the  onset 
of  pain,  fever,  leukocytosis,  etc.  The  color  of  necrotic  fibroids  is  due  to 
the  pigment  from  blood  which  becomes  laked  by  the  action  of  lipoid  sub- 
stances. 

According  to  Leith  Murray,  the  tint  of  the  tumor  varies  according  to 
the  amount  of  the  lipoid  substances  which  are  present  to  produce  the  laking 
of  blood.  Thus  we  have: 

Red  degeneration  .  .  lipoid,    just   sufficient   to   produce    perfect 

hemolysis. 

Brown,  black,  gray .  .  lipoid,  in  moderate  excess. 
Yellow  necrosis.  .  .  .lipoid,  in  excess  sufficient  to  bleach. 
White  necrosis lipoid,   insufficient   to   produce   hemolysis, 

the  latter  being  restrained  by  blood  plasma. 

RED  DEGENERATION. — This  has  assumed  considerable  clinical  impor- 
tance since  it  was  described  by  Gebhard  in  1899,  and  by  Fairbairn  in  1903. 
It  usually  occurs  in  pregnancy,  although  it  is  noted  rarely  in  nonpregnant 
conditions,  but  the  process  is  never  so  well  marked  and  complete.  The  term 
"necrobiosis"  has  often  been  used  erroneously  as  synonymous  with  red 
degeneration.  Some  employ  the  term  to  indicate  a  partial  destruction  of 
tissue  in  contrast  to  necrosis,  in  which  there  is  actual  tissue  death.  The 
terms  cannot  be  used  interchangeably,  since  red  degeneration  may  terminate 
in  complete  recovery  and  restoration  of  the  lost  vitality  of  the  tumor, 
although  usually  it  goes  on  to  liquefaction  and  total  necrosis.  Necrobiosis 
is  merely  a  phase  in  a  degenerative  alteration.  The  question  of  color  of  the 
degenerative  process  is  independent  of  the  stage  of  the  alteration  and 
dependent  only  upon  the  vascular  changes  in  the  neighborhood. 

Red  degeneration  is  essentially  an  aseptic  degenerative  process  which  is 
associated  with  hemolysis  and  autolysis  of  tissue.  Only  rarely  are  there 
invading  organisms  which  come  usually  through  the  lower  passages.  Such 
a  secondary  invasion  is  of  grave  prognostic  significance  and  fortunately  is 
not  common. 

Murray  believes  the  process  is  inaugurated  by  hemolysis  from  lipoids, 
since  the  lipoids  in  degenerating  fibroids  are  markedly  hemolytic.  He 
states  that  normally  such  action  is  held  in  check  by  blood  plasma  which 
inhibits  hemolysis.  When  the  lipoids  are  greatly  increased  in  amount,  so 
that  they  cannot  be  inactivated,  hemolysis  results  and  oxyhemoglobin  can 
be  demonstrated  by  the  spectrum.  Thrombosis  forms  from  a  deposit  of 
fibrin  in  the  blood  vessels  and  the  disintegration  of  the  blood  corpuscles. 
The  largest  thrombi  occur  in  pregnancy  and  account  for  the  pain,  the  rapid 
enlargement  of  the  growth,  and  its  softening  and  necrosis.  When  hemolysis 
continues,  the  red  coloring  matter  may  be  replaced  by  others — brown, 
yellow,  or  gray — depending  upon  the  lipoid  content  of  the  tumor.  Transi- 
tions from  red  degeneration  to  total  necrosis  are  not  uncommonly  seen 
Murray's  theory,  however,  has  not  obtained  general  acceptance.  Especially 


go  PELVIC   NEOPLASMS 

does  Ahlstrom  deny  that  the  lipoids  are  increased  in  this  condition,  since  in 
3  cases  he  found  that  they  were  either  decreased  below  normal  or  absent. 
The  other  theories  that  have  been  advanced  to  explain  this  picture  are  based 
upon  the  diminished  nutrition  which  results  from  thrombosis,  or  venous 
stasis  and  consequent  hemorrhage. 

FATTY  DEGENERATION. — Fatty  degeneration  of  uterine  fibroids  has 
occasionally  been  described  but  appears  to  be  a  rare  condition.  It  occurs 
almost  invariably  in  cases  which  have  had  large  areas  of  hyaline  degenera- 
tion which  have  become  liquefied  in  the  center.  Local  factors  apparently 
are  responsible  for  the  fatty  changes.  Lipoid  is  present,  either  in  the  form 
of  lipoid  fat  or  lipoid  soap.  It  is  a  product  derived  from  muscular  or  con- 
nective tissue  degenerations;  the  cytoplasm  passing  through  the  various 
phases  of  cloudy  swelling,  granular  and  hyaline  degeneration,  and  finally  to 
fatty  necrosis.  The  fat  globules  are  deposited  in  the  muscle  fibers,  and  fat 
is  seen  in  the  white  blood  cells  in  and  outside  of  the  lymphatics.  There  are 
signs  of  vascular  degenerations,  engorgement,  thrombosis,  and  fibrine 
deposits  in  the  vessels.  Cholestrine  crystals  may  be  found  in  the  liquefied 
cavity  in  the  center. 

The  presence  of  fat  is  not  always  a  sign  of  degeneration,  since  it  may 
be  deposited  in  fibroids  which,  to  casual  inspection,  do  not  appear  unusual. 
Only  on  careful  scrutiny  do  you  find  suggestions  of  fat.  These  tumors 
form  a  distinct  type  and  are  called  fibrolipomyomata,  or  lipomyomata. 
Knox's  case  is  typical  of  the  series,  that  is,  a  large  globular  tumor  of  typical 
adipose  appearance,  subdivided  into  a  number  of  small  areas  by  bands  of 
smooth  muscle  and  connective  tissue.  The  tumor  sprang  from  the  uterine 
wall.  R.  Peterson  described  a  submucous  lipomyoma  which  was  acci- 
dentally discovered  when  operating  for  uterine  prolapse.  The  subject  was 
early  reviewed  in  1903  by  Seydel,  who  collected  only  1 1  cases. 

The  gross  appearance  of  fatty  fibroids  is  variable.  The  whorled 
appearance  may  be  absent,  and  the  tumor  may  contain  material  resem- 
bling melted  butter;  or  the  whorled  structure  may  be  preserved,  with  a 
number  of  small  fatty  areas,  which  are  sufficient  to  give  a  cut  surface 
a  pale  yellow  color.  The  consistency  varies  with  the  degree  of  degen- 
eration, and  the  more  fat  laid  down,  the  softer  the  tumor.  The  growth 
may  be  tinted  by  soluble  blood  pigments.  Grayish  red  flocculi,  or 
streaks  of  blood,  may  be  seen  which  result  from  hemorrhage.  This 
form  of  degeneration  does  not  present  distinctive  symptoms. 

MALIGNANT  DEGENERATION. — The  old  idea  that  fibroids  did  not 
undergo  malignant  degeneration  has  been  completely  disproved  as  the 
result  of  routine  examinations  of  large  series  of  cases.  Careful  exam- 
ination of  fibroids  has  shown  that  operation  is  often  justifiable  merely 
because  of  the  average  percentage  of  malignant  changes.  Thus  if 
malignant  alterations  occur  in  3  or  4  per  cent  of  fibroids,  the  patient 
will  be  well  insured  by  an  operation  which  may  be  done  with  less  than 
one  per  cent  mortality.  The  great  majority  of  gynecologists  agree 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  91 

that  malignant  changes  are  the  most  important  condition  that  occur 
in  fibroids. 

Sarcomatous  degeneration  of  fibroids  is  usually  considered  as  the 
only  type  of  malignant  degeneration.  It  is  equally  important  to  bear 
in  mind  the  frequency  with  which  carcinoma  of  the  body  is  found  in 
uteri  presenting  myomatous  tissue:  indeed,  many,  as  Deaver,  consider 
this  the  most  important  and  serious  degeneration  initiated  by  a  fibroid. 

Sarcoma. — The  frequency  with  which  sarcoma  is  found  varies  widely, 
since  it  is  dependent  not  only  upon  the  personal  equation,  of  the  pathol- 
ogist and  his  capacity  for  diagnosing  malignant  conditions,  but  also 
upon  the  thoroughness  with  which  he  studies  all  sizes  and  types  of 
fibroids.  Sarcomatous  areas  may  easily  be  overlooked  on  gross  inspec- 
tion, unless  the  tumor  is  carefully  and  completely  sectioned.  The  need 
for  such  a  careful  routine  examination  of  fibroids  is  well  illustrated  by 
the  findings  of  Winter  in  his  two  separate  series  of  cases.  In  1907,  he 
found  that  sarcoma  was  present  in  3.2  per  cent  of  500  cases  in  which 
only  grossly  suspicious  areas  were  subjected  to  microscopic  study. 
When  every  area  of  tissue  showing  variations  from  the  normal  was 
studied  in  the  second  series  of  253  cases,  the  percentage  of  sarcoma  was 
raised  to  4.3  per  cent. 

The  frequency  of  Sarcomatous  changes  in  fibroids  is  usually  given 
at  a  lower  figure,  undoubtedly  because  fibroids  are  not  usually  sub- 
jected to  a  careful  routine  microscopic  study.  It  has  variously  been 
reported  as  fojlows : 

SARCOMATOUS  CHANGES 


Frequency  of 

Fibroids 

Percentage  sarcoma 

Fehling  

4OQ 

2 

Martin  .  . 

2CX 

2      (4  cases) 

Cullen  

14.00 

1.2  (27  cases) 

Noble  .  . 

337 

i  8 

Webster  

2IO 

i      (2  cases) 

Cullingsworth  .  . 

100  (myomata) 

i       (2  cases) 

McDowell       

IOOO 

2      (20  cases) 

Scharlieb   .  .  .•  

IOO 

i  .  6  (6  cases) 

Haultain  .  .'.'.  .  .  .  .  .  

1  20 

1.6(2  cases) 

Hirst          .  

180 

i   ?  (3  cases) 

Deaver  ...                                       

24.  C 

i  2  (4  cases) 

Collectively,  this  totals  about  2  per  cent,  but  Winter  feels,  however, 
that  if  all  tumors  were  carefully  examined,  the  true  frequency  of  this 
condition  would  be  about  4  per  cent.  Others,  as  Cullen,  state  that  the 
percentage  may  be  much  higher,  since  formerly  only  the  cases  which 
showed  gross  anatomical  changes  were  studied  microscopically. 

The  number  of  reported  cases  of  Sarcomatous  degeneration  is  con- 
stantly growing.  The  chief  discussion  concerns  the  nature  of  the 


92 


PELVIC   NEOPLASMS 


process,  whether  sarcoma  develops  secondarily  to  the  fibroid,  or 
whether  it  really  represents  a  primary  process.  Indeed,  the  possibility 
of  sarcomatous  alteration  of  fibroids  has  been  questioned  by  many. 
Clinical  data  has  supported  microscopic  evidence  of  sarcoma  develop- 
ing in  fibroids,  by  many  instances  in  which  the  growths  recurred  after 
operative  removal.  Polypi  which  were  thought  to  be  harmless  have 
also  been  followed  by  recurrences,  which  were  proved  to  be  of  a  sar- 
comatous nature.  Martin  holds  that  many  cases  believed  to  be  primary 
sarcoma  are,  in  reality,  secondary  changes  in  fibroids  that  were  not 
recognized,  and  that  the  true  frequency  of  sarcomatous  alterations  in 
fibroids  is  at  least  4  per  cent. 


FIG.  31. — MULTIPLE  FIBROIDS  WITH  SARCOMATOUS  DEGENERATION  IN  THE  LOWEST  TUMOR. 

Gross  Appearance. — Early  sarcomatous  alteration  cannot  be  recognized 
macroscopically.  When  the  malignant  state  is  well  established,  it  is 
usually  easy  of  recognition  (Fig.  31).  The  coarse,  pink,  fibrillary 
arrangement  of  the  fibroid  is  wholly,  or  in  part,  replaced  by  a  uniform, 
homogenous,  yellow  or  buff-colored  tissue.  The  sarcomatous  area  is 
usually  sharply  demarcated  from  the  surrounding  tissue,  although 
occasionally  it  merges  with  the  surrounding  structures.  It  may  pre- 
sent a  porous  appearance,  or  may  contain  large  or  small  cysts.  Most 
frequently  it  is  softened  and  is  rich  in  tissue  juices.  If  hemorrhage  has 
occurred  in  the  growth,  the  cut  surface  is  brownish  in  color,  sometimes 
gradually  fading  to  a  yellow  brown  when  blood  pigments  have  been 
deposited.  The  sarcomatous  alteration  commonly  begins  in  the  central 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


portion,  rarely  in  the  periphery.  It  is  usually  followed  by  a  coagulation 
process.  With  the  advance  of  the  growth,  secondary  foci  are  scattered 
throughout  the  uterine  wall  or  in  other  myomatous  nodules,  and  sar- 
comatous  polypi  may  project  into  the  uterine  cavity.  Sarcoma  may 
occur  in  subperitoneal,  submucous  or  interstitial  tumors.  Many  claim 
it  is  more  frequent  in  submucous  types.  This  is  substantiated  by 
Winter,  who  found  that  8.7  per  cent  of  126  submucous  fibroids  had 
become  sarcomatous,  while  Holmes  gave  5.8  per  cent  in  his  series. 
Cullen's  experience,  however,  is  to  the  contrary,  since  sarcomata  in 


FIG.  32. — MULTIPLE  FIBROIDS  WITH  ADENOCARCINOMA  OF  FUNDUS. 

interstitial  and  subperitoneal  growths  were  far  in  excess  of  those  in 
the  submucous  tumors. 

RELATION  OF  UTERINE  FIBROIDS  TO  CARCINOMA. — Carcinoma  is  not  a 
degeneration  of  a  fibroid,  as  it  must  arise  from  epithelium.  This  association 
has  been  frequently  observed,  and  it  is  worthy  of  comment  that  the 
cancers  of  the  uterine  body  are  much  more  numerous  than  those  of  the 
cervix  in  fibroid  uteri.  While  fibroids  may  be  invaded  by  cancer  of  the 
cervix  or  of  the  uterine  body,  there  is  evidence  to  believe  that  the  great 
majority  develop  as  a  result  of  the  changes  due  to  the  presence  of  the 
benign  tumor.  Many  have  called  attention  to  a  hyperplastic  condition 
of  the  uterine  mucosa  which  gradually  becomes  malignant  in  fibroid 
cases  (Fig.  32).  It  would  seem  that  this  is  a  fair  assumption  and  one 


94  PELVIC   NEOPLASMS 

which  is  also  suggested  by  the  known  tendency  of  chronic  nutritional 
and  irritative  influences  to  excite  malignant  changes.  Weibel,  in  1913, 
states  that  in  a  series  of  1,000  fibroids,  carcinoma  of  the  uterine  body 
was  found  in  20.  Noble  emphasized  the  greater  relative  frequency  of 
cancer  of  the  fundus  in  fibromatous  uteri.  He  found  that  cancer  was 
present  in  2.8  per  cent  of  4,880  cases  of  fibroids  collected  by  him. 
Cervical  cancer  occurred  in  1.29  per  cent,  and  cancer  of  the  fundus  in 
1.54  per  cent.  In  337  cases  of  his  own  series,  cancer  of  the  cervix 
occurred  in  1.4  per  cent  and  cancer  of  the  corpus  in  2.6  per  cent. 

While  there  is  a  difference  of  opinion  concerning  the  relative  fre- 
quency of  carcinoma  of  the  cervix  to  that  of  the  body  in  various  series, 
there  is  no  doubt  but  that  cancer  of  the  cervix  is  many  times  more  fre- 
quent. In  our  experience,  carcinoma  of  the  cervix  has  been  noted  twenty 
times  for  each  carcinoma  of  the  uterine  body.  Cullen's  series  gives  the 
highest  percentage  of  cancers  of  the  fundus,  occurring  once  to  four 
cases  of  cervical  cancer.  Martin  found  the  proportion  in  his  series  as 
one  cancer  of  the  fundus  to  ten  cancers  of  the  cervix.  In  2,097  cases 
collected  by  Hofmeier,  Krukenberg,  Freund,  and  Winter,  there  were 
179  cancers  of  the  uterine  body,  a  relation  of  12  cervical  carcinoma  to 
i  cancer  of  the  fundus.  On  the  contrary,  all  agree  that  more  cancers 
of  the  body  of  the  uterus  occur  in  fibroid  uteri  than  do  cervical  cancers. 

This  is  emphasized  by  the  following  statistics :  Kerr  found  only  i  cancer 
of  the  cervix  in  200  fibroid  cases,  although  there  were  6  cancers  of  the 
fundus  in  the  same  series;  Kelly  and  Cullen  found  43  uterine  cancers 
in  1,400  fibromyomatous  uteri.  Of  these,  25  were  carcinomata  of 
the  uterine  body.  Deaver  found  n  cancers  in  345  fibromyomata  of 
the  uterus.  Of  these,  6  were  cancers  of  the  body.  Winter,  in  Konigs- 
berg,  found  23  carcinomata  in  fibromyomatous  uteri,  of  which  8  were 
in  the  corpus.  In  his  Berlin  series,  he  encountered  36  cases  of  which  23 
were  in  the  fundus.  Geuer  reported  46  carcinomata  plus  fibroids,  of 
which  33  were  in  the  body.  Martin  found  9  carcinomata  in  fibroids  of 
which  7  were  in  the  body.  Hofmeier  noted  17  cancers  in  fibromyo- 
matous uteri,  of  which  9  were  corporeal.  If  the  presence  of  fibroids 
did  not  favor  the  development  of  adenocarcinoma,  we  should  expect  the 
relation  of  cervical  to  corporeal  carcinoma  to  remain  unchanged. 

Piquand  and  Winter  think  that  the  presence  of  fibroids  increases 
the  frequency  of  cervical  carcinoma.  The  evidence  for  this  view  is  less 
conclusive.  Winter  found,  in  compiling  his  own  cases  with  those  of 
Hofmeier  and  Freund,  that  carcinoma  of  the  cervix  occurred  25  times, 
or  2  per  cent,  in  1,270  fibromyomatous  uteri. 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  95 

THE  EFFECT  OF  UTERINE  FIBROIDS  ON  NEIGHBORING 
AND  DISTANT  ORGANS 

On  Uterus  and  Adnexa. — The  uterus  hypertrophies  just  as  in  preg- 
nancy under  the  influence  of  fibroid  growths  in  its  body.  The  hyper- 
trophy is  more  marked  in  the  interstitial  types  than  either  the  sub- 
mucous  or  the  subperitoneal.  It  may  occasionally  present  tremendous 
size.  Kelly  reports  a  case  in  which  the  uterus  weighed  645  grams  after 
the  removal  of  the  tumor — an  increase  of  fifteen  times  the  normal 
weight.  The  outline  of  the  uterus  changes  according  to  the  type  of 
tumor  contained  within  it.  The  form  is  usually  asymmetrical,  yet  the 
outline  may  resemble  normal  in  the  case  of  large  interstitial  and  sub- 
mucous  growths.  This  may  lead  to  confusion  with  the  diagnosis  of 
pregnancy.  The  uterine  cavity  is  much  lengthened  in  interstitial  and 
submucous  tumors,  and  may  be  distorted  in  both  shape  and  direction. 

The  individual  muscular  fibers  and  the  intermuscular  cellular  tissue 
are  markedly  hypertrophied  as  seen  by  a  microscopic  examination.  It 
may  not  occur,  however,  in  the  myometrium  which  lies  between  small 
and  numerous  interstitial  fibroids,  probably  because  of  the  pressure 
exerted  by  the  tumors.  The  outer  coatings  of  the  uterus  present  cells 
which  are  tremendously  enlarged  and  which  may  readily  be  confused 
with  those  of  midterm  pregnancy.  Individual  muscle  cells  have  attained 
a  length  of  i66/*,  and  a  breadth  of  13^^. 

The  position  of  the  uterus  will  depend  upon  the  size  and  situation 
of  the  growths.  Displacements  may  occur  in  any  direction.  Small 
fibroids  scattered  throughout  the  organ  may  not  change  the  uterine 
position.  A  tumor  on  the  posterior  wall  will  tend  to  push  the  uterus 
against  the  symphysis.  A  fibroid  on  the  anterior  wall  may  cause  a 
uterine  posterior  displacement,  and  the  fundus  may  be  forced  down 
into  the  posterior  cul-de-sac.  A  fibroid  developing  on  the  lateral  sur- 
face or  between  the  folds  of  the  broad  ligament  usually  forces  the 
uterus  to  the  opposite  side.  The  weight  of  a  large,  submucous,  pedun- 
culated  fibroid  may  cause  descent  of  the  uterus,  and  even  inversion  may 
follow  as  a  result  of  nature's  effort  to  expel  the  growth.  A  cervical 
fibroid  will  carry  the  uterus  with  it  high  into  the  abdominal  cavity. 
The  uterus  may  become  twisted  on  its  long  axis  and  present  high 
degrees  of  torsion;  rarely  the  uterine  body  may  be  partly  or  entirely 
separated  from  the  cervix  as  a  result  of  this  complication. 

The  changes  in  the  uterine  mucosa  vary,  since  it  may  be  affected  in 
the  same  manner  as  the  muscularis,  both  by  hyperemia  and  altered 
ovarian  function.  Tumors  lying  in  the  uterine  cavity  may  thin  out  the 
overlying  mucosa  by  mechanical  pressure  until  little  or  none  of  it 
remains  over  the  prominent  parts  of  the  growth.  In  such  cases,  the 
mucosa  surrounding  the  growths  is  much  thickened.  Tumors  which 


96  PELVIC   NEOPLASMS 

are  denuded  of  surface  epithelium  are  more  likely  to  undergo  degen- 
erative changes,  since  this  condition  favors  the  development  of  infec- 
tious processes. 

The  mucosa  may  be  unaltered  in  appearance  if  the  tumor  does  not 
encroach  upon  it,  or  it  may  appear  bright  red  from  capillary  injection 
or  from  foci  of  ecchymosis.  The  hemorrhagic  areas  turn  brown  or 
black  in  color  as  they  become  older. 

Dilatation  of  the  veins  of  the  mucosa  is  frequently  found,  but  def- 
inite bleeding  vessels  are  rarely  seen.  The  general  picture  suggests  a 
marked  congestion,  which  is  confirmed  by  the  gradual  oozing  which  is 
seen  from  the  vascular  system.  Edema  of  the  mucosa  is  often  very 
marked,  and  serous  fluid  escapes  from  the  cut  surfaces.  It  is  confined 
to  the  mucosa  and  usually  limited  to  small  areas.  This  may  occur  with 
any  type  of  tumor.  The  glands  may  be  normal  in  size.  Occasionally 
they  run  parallel  to  the  surface  instead  of  at  right  angles,  especially 
over  the  less  prominent  portion  of  submucous  tumors.  The  glands  are 
usually  dilated.  Sometimes  they  project  as  small  cysts  into  the  uterine 
cavity.  They  are  often  arranged  in  rows,  and  contain  a  clear,  limpid 
fluid  in  which  are  small,  yellow  bodies  composed  of  exfoliated  epithelial 
cells.  The  surface  epithelium  may  be  absent  over  markedly  dilated 
glands.  Glandular  hypertrophy  may  be  found  when  a  submucous 
tumor  is  present.  It  rarely  occurs  with  the  subperitoneal  form.  Even 
though  the  uterus  is  elongated,  the  mucosa  rarely  hypertrophies  in  this 
class  of  tumors;  more  frequently  the  mucosa  is  atrophied.  The  most 
striking  changes  in  the  uterine  mucosa  are  seen  with  the  submucous 
tumors.  Atrophy  of  the  endometrium  may  follow  counter  pressure  of 
such  a  growth  on  the  opposite  sde.  This  may  lead  to  stenosis  of  the 
cavity  and  may  be  followed  by  hydrometra,  pyometra,  or  hemato- 
metra.  Landau  has  described  a  case  in  which  serial  transverse  sections 
of  the  whole  uterus  failed  to  show  microscopic  evidence  of  a  uterine 
cavity. 

Mucous  polyps  are  commonly  found  in  association  with  fibroids. 
They  may  occur  at  any  part  of  the  wall,  but  usually  present  as  a  single 
growth  attached  to  the  fundus.  The  polyp  is  often  a  heaping  up  of  the 
mucosa.  As  it  enlarges,  it  becomes  pedunculated.  It  consists  of  a  core 
of  whitish  yellow,  semitranslueent  tissue,  and  contains  small  dilated 
glands  which  shine  through  the  uterine  mucosa,  resembling  minute 
cysts.  The  tip  of  the  polyp  is  usually  dark  red  in  color,  and  shows  small 
hemorrhagic  areas. 

Endometritis  is  rarely  noted,  even  in  the  presence  of  definite  inflam- 
mation of  the  appendages.  Exceptions  occur  when  there  are  slough- 
ing mucous  fibroids  or  when  an  involuting  puerperal  uterus  is  invaded 
by  secondary  infection.  Tuberculosis  of  the  endometrium  has  been 
found  without  invasion  of  the  fibroid.  Kelly  and  Cullen  noted  it  in  7 
out  of  1.428  cases. 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


97 


On  Tubes  and  Ovaries. — Inflammatory  conditions  are  frequently 
seen  and  often  arise  from  pressure.  Tait  found  appendage  disease  in 
54  per  cent  of  cases;  Fabricius  states  that  both  tubes  are  likely  to  be 
affected  in  the  presence  of  the  larger  tumors.  Cullen  found  adhesions 
binding  both  tubes  in  423  cases  out  of  934.  The  adhesions  were  often 
sufficiently  dense  to  cause  occlusion.  Friction  between  the  tumor  and 
the  pelvic  peritoneum  abrades  the  delicate  epithelial  cells  with  the 
resultant  formation  of  slight  adhesions.  Blocking  of  the  drainage  of 
the  uterine  cavity  or  tubes  will  cause  back  pressure,  and  the  secretions 
dam  back  and  result  in  inflammatory  changes.  McDonald's  series  of 
280  cases  presented  137  with  inflammation  of  the  adnexa.  Webster 


FIG.  33. — ADNEXAL  COMPLICATIONS  WITH  FIBROIDS. 

found  tubal  disease  in  99  of  210  cases.  Meredith  reports  tubal  disease 
in  56  per  cent  and  chronic  ovaritis  in  46  per  cent  of  Lawson  Tait's 
series.  Sloughing  fibroids  and  infections  introduced  through  the  cer- 
vix are  often  responsible  for  the  production  of  pelvic  adhesions  (Fig. 
33).  Cullen  noted  hydrosalpinx  88  times,  hematosalpinx  100  times, 
and  pyosalpinx  41  times  in  a  series  of  934  cases  (24  per  cent  of  tubal 
disease).  Tubo-ovarian  cysts  occurred  5  times,  and  tuberculous  sal- 
pingitis  14  times  in  the  same  series  of  cases.  When  there  is  no  definite 
inflammatory  change,  the  tubes  may  present  as  normal,  or  may  be 
stretched  out  over  the  tumor  and  be  enormously  elongated. 

The  ovaries  were  adherent  and  showed  some  pathological  altera- 
tions in  438  of  934  of  Cullen's  series.  Old  pelvic  adhesions  were  found 
in  48.6  per  cent  of  148  autopsies  of  women  presenting  fibroids,  at  the 
Johns  Hopkins  Hospital.  Pelvic  and  abdominal  adhesions  presented 
in  7.6  per  cent,  giving  a  total  of  56.2  per  cent  of  cases,  coming  to 


98  PELVIC  NEOPLASMS 

autopsy  in  which  fibroids  were  associated  with  adhesions  of  some 
character.  There  were  184  ovarian  cyst  formations  in  Cullen's  series. 
These  cases  presented  the  following  conditions: 

RETENTION  CYSTS 

Small  ovarian  cysts. 44 

Graafian  follicle  cysts 68 

Corpus  luteum 34 

PROLIFERATION  CYSTS 

Multilocular  cystadenoma 9 

Papillocystadenoma    12 

Adenocarcinoma 8 

Dermoids 17 

Parovarian  cyst 19 

Fibroma 3 

Enlarged  ovaries. .  .    2 

Ovarian   abscess 6 

On  the  Pelvic  Organs. —  As  the  tumor  grows,  it  is  likely  to  exert 
pressure  on  the  structures  which  normally  lie  in  the  pelvis.  Pressure 
symptoms,  as  a  rule,  develop  slowly.  They  are  most  common  in  the 
case  of  large  tumors  which  have  remained  within  the  pelvis,  although 
serious  complications  often  arise  from  pressure  by  intraligamentary 
tumors,  often  of  small  size.  Pedunculated  subserous  growths  may 
cause  pressure  symptoms  when  they  have  become  incarcerated  in  the 
pelvic  cavity.  The  bladder,  ureters,  and  rectum  are  most  likely  to  be 
affected. 

The  bladder  symptoms  vary.  Often  the  structure  is  prevented 
from  filling  in  a  normal  manner.  A  fibroid  of  the  anterior  uterine  wall 
may  compress  or  elevate  it.  Occasionally  it  is  lifted  out  of  the  pelvis 
and  when  distended  may  reach  as  high  as  the  umbilicus,  a  point  to  be 
kept  in  mind  when  making  an  incision  directly  upon  the  growth.  Ad- 
hesions between  the  fibroids  and  the  vesical  peritoneum  are  frequently 
found.  Encysted  peritonitis  containing  pockets  of  clear  serous  fluid 
is  not  infrequently  noted.  The  bladder  sometimes  becomes  sacculated 
as  the  result  of  pressure.  The  mucosa  of  the  displaced  bladder  is  nor- 
mal unless  there  has  been  obstruction  to  the  urethra,  when  retention  of 
urine  and  cystitis  are  not  uncommon.  The  bladder  wall  is  often  thick- 
ened in  such  cases  as  the  result  of  effort  to  overcome  the  partial 
blocking  of  its  drainage.  The  vesical  symptoms  in  association  with 
displacement  from  the  fibroid  vary  from  increased  frequency  of  mic- 
turition with  only  partial  emptying  of  the  viscus,  to  difficulty  in  voiding 
and  even  to  complete  blockage.  Bladder  symptoms  may  be  the  first 
complaint  made  by  the  patient  who  has  a  uterine  fibroid.  Occasionally 
they  are  the  only  subjective  symptoms. 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  99 

The  vagina  may  also  be  displaced.  Sometimes  it  is  drawn  up  and 
greatly  elongated;  in  other  cases,  it  may  be  pushed  down  by  the  weight 
of  a  tumor  not  completely  fixed  in  the  pelvis ;  and  very  rarely  it  may  be 
almost  inverted. 

The  ureters  are  frequently  involved.  Their  lower  insertions  may 
be  displaced  by  growths  which  encroach  upon  the  base  of  the  bladder. 
Intraligamentous  tumors  may  displace  them  downward,  outward,  or 
upward.  Sometimes  the  ureter  will  be  found  upon  the  top  of  an  intra- 
ligamentous  or  cervical  fibroid  in  a  position  quite  remote  from  the 
normal  one.  Pressure  on  the  kidney  may  cause  hydro-ureter,  hydro- 
nephrosis  or  even  destruction  of  the  kidney,  and  the  literature  indicates 
that  these  complications  are  more  common  than  has  hitherto  been 
emphasized.  Cullen  found  hydro-ureters  in  n  cases  of  his  series. 
Welch,  in  148  autopsies  on  fibroid  cases,  found  obstruction  5  times. 
Knox  has  shown  that  some  obstruction  was  present  in  a  large  propor- 
tion of  his  series  of  cases.  As  a  rule,  the  ureters  are  disturbed  only 
when  the  growth  is  retroperitoneal  or  spreads  out  between  the  folds  of 
the  broad  ligament. 

The  rectum  may  be  compressed,  although  complete  obstruction 
probably  never  occurs  unless  there  are  secondary  complications.  Auto- 
intoxication and  anemia  have  been  ascribed  to  partial  obstruction  by 
impacted  fibroids,  and  chronic  constipation  and  difficult  defecation  are 
quite  common.  Hemorrhoids  are  frequently  seen  in  fibroid  cases. 
Adhesions  to  the  rectum  and  sigmoid  colon  are  often  found.  This  com- 
plication occurs  most  commonly  when  there  is  pelvic  inflammatory  dis- 
ease, yet  is  often  seen  when  the  appendages  are  normal.  The  fixation 
may  be  so  dense  that  the  nourishment  of  the  tumor  is  supplied  by  the 
mesenteric  vessels  of  the  bowel.  If  the  growth  burrows  beneath  the 
mesosigmoid,  the  rectum  and  sigmoid  may  be  elevated  into  the  abdom- 
inal cavity.  Lateral  displacement  is  common  in  cases  in  which  there  is 
a  left-sided,  broad  ligament  growth.  Prolapse  of  the  rectum  or  down- 
ward displacement  of  the  canal  is  relatively  infrequent.  Pelvic 
abscesses  sometimes  occur  in  fibroid  cases,  with  the  abscess  draining 
directly  into  the  bowel.  We  have  seen  several  cases  where  a  carcinoma 
of  the  sigmoid  or  rectum  coexisted  with  a  fibroid  of  the  uterus. 

Effect  on  Distant  Organs — CARDIOVASCULAR  CHANGES. — For  many 
years,  it  has  been  well  known  that  the  mortality  following  the  removal 
of  fibroids  has  been  greater  than  should  be  expected  merely  from  the 
removal  of  the  tumor.  Even  at  the  present  time,  in  spite  of  the  remark- 
able development  of  operative  table  technic,  thrombosis  and  embolism 
often  lead  to  death.  Kazprezik,  in  1881,  called  attention  to  the  cardiac 
weakness  found  with  fibroids,  and  Hofmeier,  in  1885,  emphasized  its 
occurrence  especially  in  the  larger  tumors.  Many  pathologic  findings 
have  been  described  by  the  pathologist*  and  the  clinicians.  Brown 
atrophy  and  fatty  degeneration  of  the  heart,  atheroma  of  the  blood 


IOO 


PELVIC   NEOPLASMS 


vessels,  myocarditis,  and  endocarditis  are  commonly  observed.  The 
clinician  often  finds  cardiac  murmurs  for  the  most  part  of  hemic  origin. 
Roger  Williams  reports  the  following  findings  in  the  heart  of  32  autop- 
sies of  women  with  fibromyomatous  uteri:  valvular  heart  disease, 
mostly  chronic,  6  cases;  fatty  degeneration,  5  cases;  hypertrophy  and 
dilatation,  3  cases;  atheroma  of  the  aorta,  3  cases;  small  heart,  3  cases; 
normal  heart,  12  cases.  The  following  table  shows  the  frequency  of 
cardiac  lesions: 


Authority 

Number  cases 

Per  Cent 

Strassman  and  Lehman  (Gusserow)  .  . 
Fleck  

7i 
32=: 

48  .  8  showed  cardiac  pathology 
48           "           " 

Boldt  

70 

47      circulatory  disturbances 

Wilson  

72 

46 

Webster  

2IO 

25 

Pallanda,  as  a  result  of  his  study,  concluded,  in  1905,  that  in  the 
natural  evolution  of  fibroids,  pulmonary  embolism,  thrombosis  of  the 
pelvic  veins,  cardiac  lesions,  and  sudden  syncope  followed  in  n  per 
cent  of  cases.  Wilson  believes  that  myocardial  degeneration  was 
responsible  for  death  in  4  of  the  fatal  cases  of  his  series.  Of  Boldt's 
series,  3  of  the  5  cases  that  died  after  operation  succumbed  from  cardio- 
vascular degenerations.  Fenwick,  in  1888,  reported  22  cases  of  large 
cystic  abdominal  tumors  in  which  fatty  degeneration  of  the  heart  was 
found  at  autopsy.  Fleck,  from  his  325  cases,  concluded  that  brown 
atrophy  of  the  heart  muscle  is  characteristic  of  fibroids  without  hemor- 
rhage and  that  fatty  degeneration  of  the  myocardium  is  found  with 
hemorrhage.  In  all  of  his  autopsy  material,  definite  changes  were 
found  and  cardiac  pathology  was  proved  in  36  per  cent  of  133  cases 
which  had  not  had  hemorrhage.  Cardiac  changes  were  demonstrated 
clinically  in  34.6  per  cent  of  cases  in  which  there  had  been  no  hemor- 
rhage. They  were  found  in  some  cases  in  which  the  tumor  was  of  small 
size.  From  these  statistics  he  concludes  that  some  other  condition 
besides  loss  of  blood  was  responsible  for  the  condition  of  the  heart. 

Yet  all  do  not  agree  as  to  the  frequency  of  cardiac  complications. 
Winter  reports  the  clinical  results  in  a  series  of  266  fibromyoma  cases 
in  which  the  cardiac  findings  were  made  by  an  internalist.  The  heart 
was  normal  clinically  in  60  per  cent  of  cases,  while  30  per  cent  pre- 
sented murmurs  which  were  thought  to  be  of  hemic  origin.  Cardiac 
dilatation  and  hypertrophy  were  found  in  6  per  cent  of  cases,  and  most 
of  these  were  thought  to  be  due  to  anemia.  True  valvular  disease  was 
diagnosed  in  only  i  per  cent  of  the  series. 

There  is  much  controversy  as  to  the  cause  of  these  lesions.  Are 
these  primary  changes  in  the  heart  and  blood  vessels  due  to  the  same 
cause  which  produces  the  tumor,  or  are  they  merely  secondary  results 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  101 

and  symptoms  of  the  tumor?  Formerly,  nearly  all  believed  in  the 
so-called  "fibroid  heart,"  because  of  the  frequent  association  of  heart 
changes  and  the  large  number  of  deaths  both  before  and  after  opera- 
tion which  resulted  from  cardiovascular  lesions.  Recently,  the  belief 
has  developed  that  many  of  the  changes  are  secondary  to  the  anemia 
which  results  from  hemorrhage  or  from  disturbance  of  digestion 
induced  by  pressure  of  the  tumor.  McGlinn,  in  1914,  presented  a 
statistical  study  which  denied  the  existence  of  a  specific  "fibroid  heart." 
He  based  his  work  on  the  records  of  5,700  autopsies.  For  each  case 
with  a  uterine  fibroid,  he  took  as  control  another  case  of  the  same  age 
and  race,  without  a  fibroid.  There  were  131  fibroid  cases  which  con- 
stituted 20.75  Per  cent  of  the  632  female  bodies.  He  studied  his  cases 
as  a  unit  and  subdivided  according  to  the  decade  of  their  age  and  con- 
cluded that  a  definite  entity  of  a  "fibroid  heart"  could  not  be  sustained 
from  his  findings.  While  the  matter  cannot  be  regarded  as  finally 
settled,  there  is  little  evidence  in  favor  of  the  "fibroid  heart."  All  are 
agreed,  however,  that  the  proportion  of  deaths  from  thrombosis  and 
embolism  in  fibroid  cases  is  more  frequent  than  in  any  other  gyneco- 
logic condition,  with  the  possible  exception  of  the.  fibrosis  uteri  cases. 

KIDNEY  CHANGES. — Mention  has  already  been  made  of  the  pressure 
effect  of  fibroids  upon  the  ureters.  If  the  block  causes  back  pressure 
along  the  ureters  into  the  kidney,  a  hydronephrosis  or  pyonephrosis 
may  result.  This  mechanical  interference  is  fairly  common,  and  may 
be  of  considerable  clinical  importance.  Knox  has  reviewed  a  series  in 
Kelly's  service.  Of  great  interest,  however,  are  the  urinary  dis- 
turbances when  mechanical  interference  is  not  a  consideration,  as  may 
be  seen  when  the  fibroid  is  small  or  located  far  from  the  ureter.  The 
theory  has  been  advanced  that  toxic  effects  from  the  fibroid  act  upon 
the  kidney  parenchyma  and  accounts  for  albumin,  casts,  and  pus  cells 
which  show  in  the  urinary  analysis.  This  form  of  kidney  irritation  may 
occur  in  women  of  normal  blood  pressure,  and  who  do  not  present 
cardiac  pathology.  The  toxic  theory  is  rather  borne  out  by  the  fact 
that  the  symptoms  disappeared  only  after  the  fibroid  was  removed, 
even  though  it  did  not  exert  pressure  upon  the  ureter.  When  the  kid- 
ney damage  has  been  long  continued  and  fairly  extensive,  the  urinary 
symptoms  may  persist  for  some  time  even  after  the  removal  of  the 
tumor.  Webster  found  renal  disease  in  30  per  cent  of  his  cases  and 
held  that  the  factors  which  produced  these  changes  are  identical  with 
those  causing  cardiovascular  disturbances. 

NERVOUS  SYMPTOMS. — This  group  of  symptoms  is  often  overlooked, 
yet  is  very  apparent  in  individuals  who  appear  susceptible  to  even 
slight  absorption  of  toxic  products.  Numerous  observations  tend  to 
the  belief  that  such  patients  are  also  liable  to  the  toxicosis  of  preg- 
nancy. The  nervous  symptoms  may  be  mild,  or  so  severe  that  they 
result  in  mental  impairment.  Temporary  insanity  has  occurred  in 


102  PELVIC  NEOPLASMS 

women  with  fibroids  and  has  cleared  up  after  hysterectomy  or  myo- 
mectomy.  The  frequent  association  of  these  symptoms  even  in  women 
of  stable  nervous  system  is  too  frequent  not  to  be  considered  as  a  causal 
effect.  The  thyroid  is  also  affected  by  a  growing  fibroid  and  is  marked 
by  tachycardia,  sweating,  and  the  presence  of  a  goiter.  The  stormy 
convalescence  with  the  rapid  pulse  and  diarrhea  may  well  be  due  to 
disturbance  of  the  thyroid  balance  after  the  operative  removal  of  a 
fibroid. 


SYMPTOMS 

^W 

Fibroids  may  be  of  considerable  size  and  cause  no  symptoms  what- 
soever, and  the  presence  of  the  tumor  may  be  discovered  by  accident. 
Symptoms  arising  from  the  growth  may  present  a  wide  range  of  varia- 
tion. They  may  come  primarily  from  the  uterus,  or  may  result  second- 
arily from  effects  upon  adjacent  or  remote  structures.  The  primary 
symptoms  may  be  grouped  under  the  headings  of  hemorrhage,  leukor- 
rhea,  pressure,  pain,  dysmenorrhea,  sterility,  disturbances  in  preg- 
nancy, labor,  or  the  puerperium.  The  secondary  symptoms  include 
anemia,  nervous  disturbances,  thyroid,  kidney  and  cardiac  symptoms, 
and  complications  resulting  from  degenerative  changes,  disturbances 
in  circulation  and  mechanical  injury  to  the  tumor. 

Hemorrhage. — Hemorrhage  is  probably  the  most  common  symp- 
toms of  fibroids.  It  does  not  occur,  however,  in  all  cases,  even  in 
those  which  present  growths  of  considerable  size.  Hemorrhage  usually 
occurs  as  menorrhagia,  since  intermenstrual  bleeding  is  comparatively 
rare.  The  menstrual  flow  may  be  prolonged  or  excessive  in  amount, 
or  both  conditions  may  exist  together.  Occasionally,  the  interval 
between  the  periods  is  so  shortened  that  there  are  but  few  days  when 
the  patient  is  entirely  free  from  bleeding.  The  menorrhagia  depends 
upon  a  number  of  factors,  chief  of  which  is  the  circulatory  disturbance 
and  the  congestion  of  the  uterus  incidental  to  the  growth  of  the  tumor 
(see  blood  supply  of  fibroids,  p.  80).  It  is  generally  favored  by  the 
presence  of  hyperplasia  of  the  endometrium  and  is  precipitated  often 
by  nature's  effort  to  expel  a  submucous  tumor.  It  would  appear  that 
there  are  certain  mechanics  of  the  hemorrhage  in  fibroids.  When  the 
tumor  is  purely  interstitial,  the  hemorrhage  usually  increases  pa>ri  passu 
with  the  size  of  the  tumor.  If  it  grows  toward  the  peritoneum  the 
bleeding  may  lessen  and  even  disappear  when  the  tumor  is  extruded  as 
a  pedunculated  subserous  fibroid.  On  the  contrary,  the  bleeding 
increases  disproportionately  as  the  interstitial  form  approaches  the 
uterine  cavity.  When  the  growth  becomes  frankly  a  submucous 
tumor,  the  bleeding  may  be  most  severe.  Intermenstrual  bleeding 
occurs  when  the  submucous  fibroid  appears  at  the  cervix. 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  103 

Practically,  however,  the  mechanics  holds  true  chiefly  in  theory, 
since  fibroids  are  usually  multiple  and  all  three  varieties  may  be  found 
in  the  same  uterus.  Especial  emphasis  should  be  laid  upon  the  fact 
that  submucous  growths  occasion  hemorrhage  out  of  all  proportion  to 
the  size  of  the  tumor.  A  single  submucous  fibroid  the  size  of  a  pea  may 
occasion  more  alarming  bleeding  than  very  large  interstitial  or  sub- 
peritoneal  tumors.  Hemorrhage  is  often  so  profuse  and  of  such  long 
standing  as  to  occasion  severe  anemia,  since  there  is  not  time  for 
recuperation  in  the  few  days  in  which  there  is  no  bleeding.  The  hemo- 
globin may  fall  below  20  per  cent  and  the  red  blood  count  to  less  than 
2,000,000.  Ordinarily,  the  hemoglobin  is  between  40  and  50  in  cases 
which  come  for  treatment  presenting  this  symptom.  The  patient  is 
pale,  with  waxy,  transparent  skin,  and  suffers  from  breathlessness. 
Edema  of  the  face,  most  marked  about  the  eyelids,  is  associated  with 
the  anemia.  Secondary  symptoms  readily  follow.  Excessive  bleeding 
may  indicate  the  development  of  malignant  or  degenerative  changes, 
although  it  rarely  appears  as  the  sudden  flooding  noted  in  carcinoma. 
It  uniformly  occurs  when  submucous  growths  become  infected. 

A  noteworthy  feature  of  fibroids  is  that  they  cause  a  postponement 
of  the  menopause.  Patients  menstruating  regularly  past  the  age  of 
fifty  usually  have  fibroids.  It  is  believed  that  95  per  cent  of  patients 
menstruating  regularly  and  without  interruption  at  fifty-four  have 
fibroids.  The  history  of  bleeding  in  fibroids  differs  greatly  from  that 
in  carcinoma.  The  hemorrhage  from  carcinoma  often  comes  years 
after  the  menopause.  The  postponement  of  the  menopause,  therefore, 
strongly  suggests  the  presence  of  fibroids.  This  delay  in  the  climac- 
teric is  common  to  all  varieties  of  fibroids  and  is  not  confined  to  the 
submucous  growths. 

Internal  hemorrhage  may  occur  from  the  surface  of  subperitoneal 
fibroids.  It  comes  from  rupture  of  one  of  the  thin-walled  veins  which 
spread  over  the  peritoneal  surface  of  the  tumor.  Steinbiichel  records  a  case 
of  intraperitoneal  hemorrhage  and  collapse  following  torsion  of  a  pedun- 
culated  tumor  with  a  history  that  was  most  suggestive  of  a  ruptured 
ectopic  pregnancy.  Stein  reports  a  fatal  case  from  intraperitoneal 
hemorrhage  from  the  bursting  of  a  vein  in  the  subserous  tumor. 

Leukorrhea. — Leukorrhea  is  a  symptom  of  little  diagnostic  value. 
It  usually  represents  the  transudate  from  distended  capillaries  of  sub- 
mucous  growths  or  a  glandular  secretion  from  a  hyperplastic  endo- 
metrium.  It  may,  however,  occur  from  old  cervical  infection.  It  may 
be  thin,  watery,  and  occasionally  bloodstained,  in  the  presence  of  cystic 
tumors.  Often  it  is  extremely  irritating  and  occasions  acute  pruritus. 
The  discharge  is  foul  smelling  when  there  is  ulceration  or  gangrene  of 
the  tumor.  Like  leukorrhea  in  general,  it  is  most  noticeable  just  before 
and  after  menstruation. 


104  PELVIC  NEOPLASMS 

Pain. — Pain  is  not  a  necessary  symptom  of  fibroids,  although  it 
usually  occurs  from  one  cause  or  another.  It  indicates,  as  a  rule,  the 
advent  of  some  degeneration  or  an  infection.  Cullingsworth  found  it 
in  two-thirds  of  his  necrobiotic  cases,  in  three-fifths  of  cystic  fibroids, 
and  in  one-third  of  edematous  tumors.  Pain  is  extremely  common  in 
growths  presenting  malignant  changes.  It  also  results  from  associated 
pelvic  inflammation,  or  from  pressure  of  the  growth  upon  normally 
tender  areas.  The  pain  is  also  worse  at  the  menstrual  period.  Inter- 
menstrual  pain  may  come  from  the  uterine  contractions  which  attempt 
to  expel  a  growth  from  its  body,  as  when  an  interstitial  tumor  is  about 
to  become  either  subserous  or  submucous  and  when  submucous  tumors 
have  been  so  detached  that  they  represent  a  foreign  body.  The  fre- 
quency with  which  pain  occurs  with  malignant  changes  should  be  con- 
sidered as  of  diagnostic  value  and  should  at  least  arouse  the  suspicion 
that  the  growth  is  no  longer  benign. 

Dysmenorrhea. — As  we  have  noted,  pain  may  occur  from  uterine 
contractions  in  the  effort  to  expel  a  submucous  growth  or  blood  clots 
which  result  from  excessive  bleeding.  This  type  of  dysmenorrhea  is 
coincident  with  the  flow  and  is  frequently  described  as  resembling  the 
pains  of  labor.  Dysmenorrhea  is  not  common  with  interstitial  or  sub- 
serous  tumors  and  when  preesent  may  be  difficult  to  explain  unless  there  is 
associated  pelvic  peritonitis.  It  is  normally  present  in  adenomyoma  (q.  v. ). 

Pressure  Symptoms. — Pressure  symptoms  are  not  uncommon  and 
are  dependent  upon  the  size  and  position  of  the  tumor.  A  small  intra- 
ligamentous  tumor  may  occasion  far  more  symptoms  when  incarcer- 
ated than  a  large  pedunculated  subperitoneal  growth  that  is  free  in  the 
abdomen.  Nerve  pains  in  the  lower  limbs  may  be  the  only  complaint. 
This  is  well  illustrated  by  a  recent  instance  in  our  service  in  which  the 
woman  complained  only  of  numbness  and  tingling  in  her  left  leg  for 
six  months.  There  were  no  menstrual  disturbances  and  the  patient 
was  totally  unaware  of  a  large  tumor.  At  operation,  multiple  inter- 
stitial and  subperitoneal  fibroids  were  found  and,  jammed  in  the  cul-de- 
sac,  was  a  partially  impacted  tumor,  the  size  of  an  orange,  which  was 
occasioning  the  pain. 

Bladder  Symptoms. — These  have  already  been  mentioned.  In  spite 
of  its  close  relation  with  the  uterus,  disturbance  of  its  functional 
activity  is  rather  infrequent,  on  account  of  its  mobility  and  ability  to 
distend  in  the  plane  of  least  resistance.  Fibroids  confined  to  the  pelvis 
are  more  likely  to  occasion  pressure  symptoms.  The  pressure  is 
diminished  and  the  symptoms  tend  to  disappear  when  the  growth  has 
so  enlarged  that  it  rises  into  the  abdominal  cavity.  As  long  as  the  dis- 
tensibility  of  the  bladder  is  not  interfered  with,  and  there  is  no  en- 
croachment which  limits  the  extent  of  its  capacity,  the  organ  is  very 
tolerant  of  displacement.  The  bladder  may  be  found  adherent  to  the 
anterior  surface  of  large  uterine  tumors,  and  may  be  drawn  up  into 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  105 

the  abdomen  as  high  as  the  umbilicus  without  occasioning  any  vesical 
symptoms. 

Frequent  urination  occurs  in  about  88  per  cent  of  women  with 
fibroids.  Only  occasionally  is  tenesmus  or  dysuria  present.  There  is 
usually  a  feeling  of  weight  and  discomfort.  Retention  of  urine  is  not 
frequent.  It  occasionally  results  suddenly  because  of  the  impaction  of 
a  fibroid  uterus.  The  urethra  is  rarely  compressed,  although  the  lumen 
may  be  narrowed  from  elongation  and  stretching  of  the  duct. 


DIAGNOSIS 

The  diagnosis  of  uterine  fibroids  usually  occasions  little  difficulty. 
Occasionally,  however,  it  is  extremely  difficult,  especially  in  the  small 
submucous  and  large  interstitial  types  of  tumors.  The  diagnosis  is 
based  chiefly  upon  the  results  of  bimanual  palpation,  although  some- 
times it  may  be  made  purely  by  abdominal  palpation.  The  history  of 
the  case  is  most  useful  in  aiding  the  differential  diagnosis,  although  the 
pelvic  condition  finally  rests  upon  the  pelvic  examination.  Symptoms 
are  subjective  and  objective.  Subjectively  a  woman  usually  of  middle 
life  gives  a  history  of  hemorrhage,  dysmenorrhea,  and  other  pelvic 
symptoms  which  may  have  extended  over  a  considerable  time.  The 
patient  may  or  may  not  have  had  symptoms  of  pressure  or  be  con- 
scious of  the  presence  of  the  tumor.  Often  there  is  a  history  of  sterility 
or  of  frequent  abortion.  The  patient  usually  has  gained  weight. 
Emaciation  is  rarely  noted,  and  is  confined  practically  to  the  cases  pre- 
senting enormous  tumors.  Objectively,  there  are  symptoms  of  anemia 
when  there  has  been  bleeding  of  long  duration.  The  skin  is  pale,  yellow 
and  white  in  the  anemia  following  fibroids  in  which  it  differs  from  the 
yellow  brown  of  the  cachexia  of  cancer.  On  bimanual  examination, 
the  uterus  is  enlarged  and  often  of  irregular  outline.  Since  fibroids  are 
usually  multiple,  there  are  knobs  or  bosses  of  subperitoneal  tumors. 
The  uterus  is  usually  firm,  yet  is  not  always  hard  nor  of  irregular  out- 
line. Frequently,  it  is  soft  and  rounded,  and  may  readily  be  confused 
with  pregnancy  and  cause  much  difficulty  in  the  diagnosis.  Occasion- 
ally the  diagnosis  cannot  be  made  until  the  cervix  is  dilated  and  a 
polypoid  growth  felt  within  the  uterine  cavity. 

The  appearance  of  fibroids  varies  so  considerably  that  the  question 
of  diagnosis  is  best  presented  according  as  the  tumors  are  large  or 
small. 

Diagnosis  of  Small  Fibroids. — Small,  submucous,  pedunculated 
fibroids  above  the  level  of  the  internal  os  are  often  recognized  only 
after  the  uterine  canal  has  been  dilated  sufficiently  to  admit  a  sound, 
or  occasionally  a  palpating  finger.  The  whole  uterus  is  usually  more 
or  less  symmetrically  enlarged  and  is  harder  than  a  pregnant  uterus, 


I06  PELVIC   NEOPLASMS 

although  softer  than  the  normal.  The  enlargement  may  readily  be 
mistaken  for  a  metritic  uterus  or  that  seen  in  premenopausal  conges- 
tion. Hegar's  sign  of  pregnancy  is  absent,  nor  are  there  intermittent 
uterine  contractions. 

Tumors  which  present  through  the  cervix  may  be  mistaken  for 
pedunculated  sarcoma,  or  the  placental  remains  of  an  abortion.  Their 
appearance  varies  according  as  the  tumor  is  covered,  or  not  covered, 
with  mucosa.  Tumors  which  are  sensitive  to  pain  are  covered  with  a 
deeply  injected  mucosa.  An  inverted  uterus  is  readily  recognizable  in 
the  majority  of  cases.  The  peduncle  usually  is  palpable  as  a  stalk  com- 
ing down  through  the  cervical  canal.  Ulcerated  or  gangrenous  tumors 
may  readily  be  confused  with  malignant  growths.  In  case  of  doubt, 
the  patient  should  be  examined  under  anesthesia  and  the  cavity  of  the 
uterus  explored  with  the  finger  or  the  sound  unless  there  are  contra- 
indications for  anesthetics.  It  is  very  difficult  to  diagnose  small,  sub- 
mucous,  nonpedunculated  tumors.  Even  after  the  cervix  has  been 
dilated,  they  may  not  be  recognized  with  a  curette  or  sound,  although 
this  is  unusual.  The  uterus  is  increased  in  size  and  more  rounded  than 
normal.  There  is  history  of  bleeding. 

Small  interstitial  tumors  may  escape  recognition,  although  they 
usually  cause  asymmetry  of  the  uterus.  When  low  down,  they  may 
bulge  into  the  cervix  and  rarely  simulate  inversion. 

Small  peritoneal  tumors  usually  produce  a  slight  bulging  on  the 
surface  of  the  uterus.  They  are  more  or  less  movable,  but  their  form 
and  consistency  depends  on  various  conditions.  Pedunculated  growths 
may  simulate  ovarian  swellings,  when  the  tumor  is  pedunculated  and 
projects  from  one  side  of  the  uterus.  The  diagnosis  is  easy  when  both 
ovaries  can  be  palpated,  yet  this  may  be  impossible. 

Intraligamentous  growths  are  readily  diagnosed.  They  are  usually 
situated  low  down  in  the  pelvis  and  come  within  easy  reach  of  the 
examining  finger.  Sometimes  they  even  project  into  the  vagina. 

Diagnosis  of  Large  Uterine  Fibroids. — The  diagnosis  usually  offers 
no  difficulty  when  the  tumor  is  irregular  in  outline.  When  the  growth 
is  subperitoneal,  its  connection  with  the  uterus  can  usually  be  demon- 
strated by  an  assistant  making  traction  on  the  pedunculated  growth 
while  the  surgeon  makes  a  bimanual  examination  of  the  uterus.  This 
type  of  tumor  is  frequently  confused  with  ovarian  cyst.  Cysts  of  large 
size  with  long  pedicles  usually  go  to  the  center  of  the  abdomen.  Uter- 
ine fibroids  which  are  regular  in  outline  may  give  the  greatest  diffi- 
culty in  differentiation  from  pregnancy. 

The  examination  should  proceed  according  to  the  accepted  methods 
of  inspection,  palpation,  percussion  and  auscultation. 

INSPECTION. — This  frequently  gives  diagnostic  aid.  A  fibroid  large 
enough  to  distend  the  whole  abdomen  is  commonly  located  more  or  less  on 
one  side  of  the  median  line,  yet  this  is  not  invariable.  If  small  nodules  are 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  107 

seen  through  the  abdomen,  there  is  strong  presumptive  evidence  of  fibroid 
tumor.  The  contour  of  the  abdomen  usually  drops  suddenly  to  its  normal 
level  above  the  upper  confines  of  the  tumor,  while,  in  ovarian  cysts  and 
pregnancy,  the  descent  is  more  gradual.  A  linea  negra  may  be  present, 
although  rarely  as  well  marked  as  in  pregnancy. 

PALPATION. — The  outline  may  be  regular  or  irregular.  Irregular  shapes 
rarely  give  trouble  in  diagnosis.  Fibroids  are  essentially  uterine  growths. 
On  pushing  the  tumor  from  side  to  side,  the  uterus  should  be  felt  to  move 
coincidently.  Pedunculated  nodules  on  a  tumor  mass  are  strongly  pre- 
sumptive of  fibroids.  The  diagnosis  is  more  confusing  if  the  growth  is 
detached  from  the  uterus  and  has  become  parasitic.  Intermittent  contrac- 
tions are  usually  absent;  probably  they  occur  only  in  soft  fibroids.  Colo- 
strum is  sometimes  seen  in  the  breasts  of  women  who  have  never  had 
children.  Therefore,  its  presence  may  not  differentiate  absolutely  be- 
tween fibroids  and  pregnancy. 

PERCUSSION. — The  percussion  note  is  flat  unless  the  growth  is  covered 
with  distended  intestines.  The  flanks  are  resonant  unless  the  abdomen  con- 
tains free  fluid.  Movable  dullness  is  apparent  in  ascites  and  in  subperitoneal 
tumors  which  are  large  and  mobile. 

AUSCULTATION. — This  is  chiefly  of  value  in  excluding  the  presence  of 
a  fetal  heart  in  large  symmetrical  uterine  tumors.  A  uterine  souffle  is 
usually  heard  at  the  sides,  although  it  may  be  present  over  the  surface  of 
the  tumor.  It  is  not  of  diagnostic  value,  since  it  occurs  in  all  conditions 
which  have  enlarged  veins  of  the  broad  ligament. 

VAGINAL  EXAMINATION. — The  vaginal  mucosa  seldom  gives  a  color 
which  may  be  confused  with  the  changes  seen  in  pregnancy.  Occasionally 
it  presents  a  bluish  color,  yet  only  most  rarely  does  it  have  a  purplish  tinge. 
The  cases  of  pregnancy  which  are  most  likely  to  be  confused  with  fibroids 
do  not  have  the  characteristic  purple  discoloration.  The  cervix  may  be 
variously  displaced  and  is  usually  of  firm  consistency.  Occasionally  its  tip 
is  softened.  The  lower  uterine  segment  is  rarely  as  symmetrical  as  in  preg- 
nancy. At  times,  however,  the  outline  is  perfectly  regular  and  symmetrical. 
On  the  bimanual  examination,  we  find  an  enlarged  uterus  and,  when  there 
are  pedunculated  subserous  growths,  masses  which  appear  quite  distinct 
from  the  tumor.  Ordinarily,  however,  we  feel  a  large  uterine  mass  which 
is  continuous  with  the  cervix. 

Differential  Diagnosis. — The  differential  diagnosis  lies  chiefly  be- 
tween fibroids,  ovarian  cysts  and  normal  pregnancy.  Ovarian  cysts 
are  usually  softer  and  more  symmetrical  than  fibroids,  although  the 
differentiation  is  sometimes  quite  impossible.  If  two  ovaries  are  felt 
and  there  is  still  a  mass  in  the  pelvis,  presumably  the  growth  is  a 
fibroid.  Pedunculated  fibroids,  however,  may,  when  of  small  size,  be 
confused  with  ovaries. 

Uterine  preguancv  advanced  as  far  as  the  fifth  month  may  offer 
the  greatest  difficulty  in  the  differential  diagnosis.  Cases  are  frequently 


io8 


PELVIC   NEOPLASMS 


operated  as  tumors  and  the  true  diagnosis  obtained  only  when  the  abdomen 
is  opened.  The  diagnosis  may  rest  upon  hearing  the  fetal  heart,  or  upon 
the  findings  of  the  X-ray,  when  the  tumor  is  as  symmetrical  as  the  pregnant 
uterus.  Occasionally,  even  when  the  abdomen  is  opened,  one  may  be  most 
uncertain  as  to  the  nature  of  the  growth,  especially  when  it  has  to  be  differ- 
entiated from  a  two-  or  three-months  pregnancy  (Figs.  34,  35).  Even  with 
growths  of  larger  size,  the  surgeon  may  be  convinced  that  he  is  feeling  the 


FIG.  34.— CYSTIC  FIBROID  SUGGESTING  FOUR  MONTHS'  PREGNANCY. 

outlines  of  a  fetus.  There  is  no  surgeon  of  experience  who  has  not  had  cases 
which  proved  to  be  most  confusing.  Ordinarily,  the  history  of  menstru- 
ation will  help  to  determine  the  diagnosis.  Yet  when  there  is  reason  for 
deception,  subjective  symptoms  are  not  of  value. 

Ectopic  gestation  may  be  readily  confused  with  fibroids,  especially  if 
the  pregnancy  is  situated  in  an  undeveloped  uterine  horn.  It  is  often  quite 
impossible  to  arrive  at  a  diagnosis  in  case  there  is  pregnancy  in  a  double 
uterus  which  also  contains  fibroids.  We  have  seen  such  a  case  in  which  the 
small  tumor  in  the  uterine  horn  was  confused  with  an  ectopic.  Both  ovaries 
were  present,  the  uterus  was  enlarged,  the  patient  had  had  bleeding,  sug- 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX 


109 


gesting  the  extrusion  of  a  uterine  membrane.  .  Theoretically,  time  is  neces- 
sary to  establish  a  diagnosis  of  pregnancy.  Yet  naturally  there  should  be 
no  delay  in  determining  the  presence  of  an  extra-uterine  pregnancy.  While, 
as  a  rule,  the  hardness  of  the  tumor  and  the  absence  of  the  signs  and  symp- 


3.  35-— LATERAL  VIEW  OF  FIG.  34.     Note  cystic  spaces  in  lower  pole  of  tumor. 


toms  of  pregnancy  may  strongly  suggest  the  nature  of  the  condition,  the 
true  diagnosis  may  not  be  possible  until  the  abdomen  has  been  opened. 
When  the  uterus  is  greatly  enlarged  by  the  tumor,  the  condition  may  re- 
semble that  of  advanced  tubal  pregnancy,  in  which  there  has  been  death 
of  the  fetus  and  absorption  of  the  liquor  amni.  The  literature  contains 


no  PELVIC   NEOPLASMS 

many  reports  of  such  cases.     If  doubt  still  exists  after  the  careful  physical 
examination,  X-ray  pictures  are  indicated. 

Pelvic  inflammatory  masses  do  not  usually  simulate  a  fibroid  tumor. 
Occasionally,  however,  the  differential  diagnosis  is  nearly  impossible,  espe- 
cially when  there  has  been  suppurative  peritonitis  with  extensive  exudate 
which  has  undergone  organization.  In  most  cases,  the  history  aids  the 
diagnosis,  yet  sometimes  it  may  give  no  help.  In  this  connection,  we  should 
remember  the  frequent  association  of  pelvic  inflammatory  and  fibroid. 

Cancer  of  the  ovary  and  involvement  of  the  pelvic  tissues  in  general 
may  be  differentiated  from  fibroid  by  the  firmness  of  the  infiltration,  its 
fixity  and  the  lack  of  outline  which  is  characteristic  of  fibroid  tumors. 
Occasionally  the  nature  of  the  condition  wrill  not  be  recognized  until  the 
abdomen  is  opened. 

Cancer  of  the  rectum  with  impaction  of  feces  is  often  mistaken  for 
fibroids,  when  the  inspissated  feces  project  into  the  abdominal  wall  and 
suggest  fibroid  nodules.  At  times,  the  two  conditions  exist  together. 

Sarcoma  associated  u'ith  fibroids  may  also  be  confusing.  If  the  dic- 
ease  has  extended  to  the  endometrium,  it  may  be  recognized  by  tissue  re- 
moved by  the  curette  in  case  the  surgeon  curettes  fibroid  growths  before 
operation.  Often,  however,  the  malignant  areas  have  not  extended  into 
the  endometrium,  or  cannot  be  reached  by  the  curette,  and  a  diagnosis  is  not 
made  until  the  tumor  is  removed  and  opened,  and  sometimes  not  until 
the  advent  of  metastases  which  give  symptoms. 

Other  conditions  may  be  mistaken  for  fibroids.  Displaced  kidneys  or 
spleen  may  prolapse  to  the  pelvis  and  give  difficulty  in  diagnosis.  In  the 
presence  of  adhesions,  a  diagnosis  may  not  be  possible.  The  notch  on  the 
spleen  is  usually  palpable  in  enlargement  of  that  organ. 

Prognosis,  without  Treatment. — The  prognosis  of  fibroids  without 
removal,  X-ray  or  radium  treatment  is  still  a  matter  of  contention. 
There  is  no  doubt  that  small  growths  which  are  not  giving  symptoms 
may  cause  little  or  no  danger  and  may  shrink  during  the  menopause. 
Roger  Williams,  in  1901,  concluded  that  only  I  of  3,000  cases  of 
fibroids  proved  fatal  without  operation.  This  report  was  based  upon 
the  Registrar  General's  statistics  for  Great  Britain,  in  which  there  were 
339  deaths  attributed  to  uterine  fibroids  without  operation  in  a  popu- 
lation of  17,000,000  women.  In  preparing  his  tables,  he  calculated  that  20 
per  cent  of  women  over  thirty-five  years  in  this  series  had  fibroids.  There 
are  many  objections  to  these  tables,  interesting  though  they  are.  Sta- 
tistics derived  from  such  sources  are  usually  incomplete;  especially  in 
fibroids,  which  do  not  usually  kill  per  se  but  cause  alteration  as  a  result  of 
anemia  and  kill  only  rarely  because  of  malignant  changes.  There  is 
a  considerable  literature  which  has  reviewed  deaths  without  operation. 
Pallanda  studied  171  such  fatal  cases.  Winter  concluded  that  death 
resulted  from  the  effect  of  the  tumor  after  a  longer  or  shorter  period 
in  10  per  cent  of  cases.  Noble  calculated  that  12  per  cent  of  his  2,274 


BENIGN  TUMORS  OF  UTERUS  AND  CERVIX  in 

collected  cases  would  have  died  from  degenerations  or  complications 
which  existed  in  the  tumor  if  the  growth  had  not  been  removed.  He 
states  that  11  per  cent  would  have  died  as  a  result  of  complications 
which  were  present  in  the  uterine  appendages  or  abdomen  without 
treatment.  In  addition,  there  existed  in  his  series  numerous  other 
complications  which  caused  invalidism.  He  states,  finally  basing 
his  conclusions  on  pathology  seen  in  the  operating  room,  that  approxi- 
mately 30  per  cent  of  all  women  having  fibroid  tumors  of  large  size 
would  die  in  the  natural  development  of  the  disease  or  its  complica- 
tions, without  surgical  interference. 

While  it  may  be  true  that  Noble  has  exaggerated  the  influence  of 
these  tumors,  there  is  abundant  evidence  that  they  may  not  be  taken 
lightly.  The  loag  list  of  fatalities  recorded  in  the  literature  shows  that 
such  women  may  die  without  operation.  The  anemia  so  often  seen 
in  fibroid  cases  is  so  marked  and  so  resistant  to  treatment  that  in  itself 
it  constitutes  a  considerable  source  of  danger.  Degenerative  changes 
in  the  cardiovascular  system  and  in  the  kidney  are  frequent.  There  is 
abundant  proof  that  malignant  changes  in  the  tumor  occasion  a  mor- 
tality at  least  twice  that  of  surgical  interference  in  proper  hands.  Com- 
plications which  occur  in  the  event  of  pregnancy  may  kill  during  labor 
or  the  puerperium.  Although  we  are  not  of  the  mind  to  accept  Noble's 
statistics  as  a  whole,  we  believe  that  there  is  no  doubt  that  the  danger 
from  leaving  tumors  the  size  of  a  man's  fist  or  greater  which  are 
causing  symptoms,  and  the  small,  but  troublesome,  submucous 
growths,  is  three  or  four  times  that  which  occurs  from  their  removal. 

LITERATURE 

DEAVER.     Treatment  of  fibroids.    Am.  J.  Obst.     58:257. 

FLECK.     Archiv  fur  Gynakologie,  Vol.  71. 

LEITH-MURRAY.     The  Haemolytic  Lipoids  of  Degenerating  Fibroids.     J. 

Obst.  &  Gynec.  Brit.  Emp.     1910.     17:534. 
McGLiNN.    The  Heart  in  Fibroid  Tumors  of  the  Uterus.     Surg.,  Gynec.  & 

Obst.     1914.     18:180. 
POLAND.     Ueber  die  Lymphbahnen  der  Myome.     Zeitschr.  f.  Geb.  u.  Gyn. 


SAMPSON.     The  Effect  of  Myomas  on  Blood  Supply  of  Uterus.     Surg., 
Gynec.  &  Obst.     1913.     16:144. 


CHAPTER  VI 

FIBROIDS 

Expectant  treatment — Systemic  medication — Discarded  methods — Non-radical  operative 
treatment — Palliative  treatment — Treatment  of  fibroids  by  radiotherapy — Roentgen-ray 
treatment  of  fibroids — Method  of  action — Indications  and  centra-indications  for  treat- 
ment— Results  of  X-ray  treatment — Treatment  of  fibroids  by  radium — Indications — 
Centra-indications — Method  of  action — Technic — Dosage — Results  of  treatment — 
Radical  treatment — Positive  indications  and  centra-indications  for  operative  treat- 
ment— Myomectomy,  Mortality  of — Abdominal  myomectom}' — Technic  in  superi- 
toneal  fibroids — Interstitial  fibroids — Intraligamentous  fibroids — Vaginal  myomectomy 
— Technic  of  pedunculated,  submucous  fibroids — Nonpedunculated  submucous  fibroids 
— Interstitial  fibroids— Subperitoneal  fibroids — Cervical  fibroids — Abdominal  hyste- 
rectomy— Historical — General  remarks — Technic — Supravaginal  hysterectomy — Pan- 
hysterectomy — Various  modifications — Relation  between  fibroids  and  pregnancy — 
Sterility — Effect  of  pregnancy  on  fibroid — Abortion — Fetal  position— Labor — Puerpe- 
rium — Treatment. 


TREATMENT  OF  FIBROIDS 

The  treatment  of  fibroids  has  undergone  profound  revision  during 
the  last  few  years.  The  great  majority  of  measures  formerly  advocated 
as  palliative  have  been  superseded  by  the  treatment  with  radium  or 
the  X-ray.  The  excellent  results  now  obtained  by  surgical  removal 
make  radical  treatment  the  method  of  choice  in  the  absence  of  contra- 
indication to  operation.  The  tremendous  reduction  in  the  mortality 
following  operation  has  been  obtained  by  radical  improvements  in 
operative  technic  and  by  bringing  patients  to  operation  in  better  con- 
dition to  stand  surgical  procedure.  Improved  methods  for  the  trans- 
fusion of  blood  have  done  much  to  make  good  results  possible. 

Expectant  Treatment. — It  does  not  follow  that  all  growths  require 
active  treatment.  Many  are  small  and  do  not  present  symptoms,  and 
are  discovered  only  accidentally  in  the  course  of  physical  examination. 
This  type  of  patient  should  be  kept  under  observation  and  watched 
carefully,  especially  if  she  is  nearing  the  usual  menopause  age.  The 
very  great  majority  of  small  growths  shrink  markedly  in  size  after  the 
menopause.  The  patient  should  be  observed  at  intervals  of  five  or  six 
months  and  the  findings  should  be  carefully  reported.  Thus  the 
physician  will  be  able  to  recognize  any  sudden  increase  in  size  of  the 
fibroids  and  early  learn  of  the  advent  of  symptoms.  Both  the  patient 

112 


FIBROIDS  113 

and  the  physician  should  be  reconciled  to  the  fact  that  the  menopause 
is  very  likely  to  be  greatly  delayed. 

Systemic  Medication. — Medicines  usually  do  little  to  control  the 
symptoms  of  fibroid.  In  the  early  days  of  surgery,  they  enjoyed  wide 
vogue  for  the  control  of  hemorrhage,  yet  the  results  were  most  uncer- 
tain and  at  best  were  transient.  At  the  present  time,  they  are  useful 
only  as  temporary  measures  and  naturally  come  into  competition  with 
the  transfusion  of  blood  as  a  means  of  getting  the  patient  in  better 
condition  for  radical  measures.  Ergot  and  hydrastis  canadensis  were 
the  drugs  usually  employed.  Ergot  was  advocated  by  Hildebrandt  in 
1872  with  the  idea  that  it  controlled  menorrhagia,  reduced  the  nutri- 
tion of  the  tumor  by  cutting  down  the  blood  supply,  and  favored  the 
expulsion  of  submucous,  pedunculated  growths.  Time  has  shown  that 
cases  respond  so  rarely  to  treatment  with  ergot  that  it  is  no  longer 
warranted  as  a  routine  measure.  Moreover,  it  may  do  harm.  Modern 
investigations  have  shown  that  failure  of  such  treatments  is  due  to 
two  causes:  (i)  the  lack  of  a  standard  preparation  of  ergot;  and  (2) 
the  bleeding  comes  from  the  venous  side  of  the  capillary  system  and 
is  not  likely  to  respond  to  treatment.  Even  though  the  drug  might 
theoretically  diminish  the  circulation  in  the  uterus  proper,  it  could  not 
control  bleeding  which  comes  from  the  smaller  vessels  of  the  endo- 
metrium.  Granting  that  ergot  might  excite  the  uterus  to  tetanic 
contractions  and  favor  the  expulsion  of  a  polyp  from  its  bed,  there  is 
every  reason  to  believe  that  the  loss  of  blood  attending  this  process 
would  more  than  outweigh  its  advantages.  Practically,  however,  there 
is  little  use  for  a  theoretic  discussion,  since  ergot  causes  extrusions 
of  polyps  only  in  the  rarest  of  cases.  It  does  not  seem  worth  while, 
therefore,  to  delay  operation  for  polypoid  growths,  since  these  often 
may  be  removed  by  a  comparatively  minor  operation.  Hydrastis 
canadensis  w7as  formerly  used  by  nearly  all  clinicians,  yet  the  work  of 
laboratory  pharmacologists  has  shown  that  it  is  useless  for  the  control 
of  hemorrhage,  a  fact  which  had  been  suspected  by  nearly  all  who 
used  it  in  treatment.  Adrenalin  occasionally  is  useful  as  a  temporary 
measure  to  control  the  bleeding.  A  long  list  of  other  drugs  has  been 
used  from  time  to  time,  but  their  very  number  shows  that  none  have 
been  specific.  The  only  treatment  by  drugs  which  we  have  found  of 
use,  when  the  patient's  condition  did  not  demand  transfusion,  and 
we  were  trying  to  check  the  menstrual  flow  so  that  she  might  come 
to  operation  in  better  condition,  is  a  combination  of  ergotin  (grains  i), 
stypticin  (grains  i)  and  hydrastinin  (grains  ss.)  given  in  the  form  of 
a  pill  four  times  daily  beginning  the  day  the  flow  threatens. 

Every  patient  with  fibroids  should  be  put  upon  a  proper  hygiene 
and  diet,  irrespective  of  plans  for  subsequent  treatment. 

Discarded  Methods. — Formerly,  electricity  was  advocated  as  a 
means  not  only  of  controlling  the  bleeding  but  of  reducing  the  size  of 


n4  PELVIC   NEOPLASMS 

the  tumor.  It  was  introduced  by  Tripier,  of  Paris,  although  Apostoli 
was  responsible  for  the  wide  vogue  which  it  formerly  enjoyed.  At 
the  present  time,  it  has  been  discarded  by  nearly  all  men  of  experience. 
The  reports  of  many  commissions  of  societies  appointed  to  investigate 
the  results  were  uniformly  discouraging  save  for  an  occasional  tem- 
porary arrest  of  hemorrhage.  This  advantage  was  more  than  offset 
by  infection  which  followed  its  use. 

Curettage,  like  the  preceding,  was  advocated  and  universally  em- 
ployed in  the  days  when  abdominal  surgery  carried  a  high  mortality. 
Unfortunately,  it  cannot  be  used  in  the  majority  of  cases  in  which 
bleeding  is  a  threatening  symptom,  since  the  uterine  cavity  is  usually 
distorted  and  the  curette  cannot  follow  its  course.  When  the  uterus 
can  be  curetted,  the  results  are  but  temporary,  since  the  endometrium 
regenerates  in  a  few  days,  because  the  condition  causing  symptoms 
has  not  been  removed. 

Other  measures,  that  is,  the  intra-uterine  application  of  various 
drugs,  as  iodin,  the  tincture  or  chlorid  of  iron,  formalin,  etc.,  have  been 
used  and  abandoned.  A  few  years  ago,  atmokausis  was  advocated 
and  used  by  a  number  of  German  clinicians.  The  method  was  followed 
by  a  few  good  results  and  a  large  number  of  complications. 

Nonradical  Operative  Treatment. — In  the  early  days  of  abdominal 
surgery,  when  the  mortality  attending  the  removal  of  fibroids  was 
extremely  high,  various  nonradical  methods  were  advocated  and  prac- 
ticed in  cases  when  it  did  not  seem  wise  to  attempt  removal  of  the 
tumor  after  the  abdomen  had  been  opened.  Salpingo-oophorectomy 
was  described  by  Tait,  in  1872,  and  subsequently  was  adopted  by  a 
large  number  of  surgeons.  Naturally,  this  method  was  attempted  only 
in  cases  that  did  not  have  pelvic  inflammatory  disease.  It  secured  bene- 
ficial results,  probably  because  of  the  establishment  of  the  artificial 
menopause,  following  which  the  tumor  atrophied  in  the  great  majority 
of  cases.  At  the  same  time,  it  was  responsible  for  many  distressing 
sequelae  because  proper  peritonealization  was  impossible  and  abdomi- 
nal adhesions  were  the  rule.  Occasionally,  the  arrest  of  hemorrhage 
was  only  temporary.  Sometimes  the  result  was  delayed  for  many 
months.  In  other  cases,  the  tumor  did  not  shrink  in  size  but  continued 
to  grow.  Nor  was  the  operation  by  any  means  as  safe  or  as  easy  as 
an  ordinary  salpingo-oophorectomy  because  of  the  vascularity  of  the 
pelvis  and  the  extent  of  adhesions.  Infection  was  common. 

For  these  reasons,  others  advocated  less  radical  measures. 
Schroeder  and  Antal  practiced  the  ligation  of  the  ovarian  vessels  and, 
in  1889,  Rydygier  tied  the  ovarian,  uterine,  and  round  ligament  arte- 
ries, although  the  results  were  not  entirely  successful.  In  1893,  Frank- 
lin Martin  proposed  the  ligation  of  the  uterine  vessels  through  the 
vagina,  and  this  operation  was  subsequently  taken  up  by  a  large 
number  of  Continental  surgeons.  It  was  found  of  value  in  tumors 


FIBROIDS  115 

no  larger  than  an  orange.  With  the  reduction  of  the  mortality  and 
complications  attending  radical  removal,  these  measures  have  been 
supplanted  by  hysterectomy. 

Palliative  Treatment. — This  has  as  its  object  only  the  control  of 
hemorrhage,  since  the  other  symptoms  are  not  likely  to  respond  to 
treatment.  Our  chief  reliance  should  be  placed  in  X-ray  and  radium 
for  palliative  treatment,  with  the  idea  of  inducing  the  menopause  so 
that  cessation  of  bleeding  will  result  from  this  cause.  Other  general 
methods  should  be  used  as  adjuvant  treatment,  with  the  idea  of  build- 
ing up  the  patient's  general  condition. 

Treatment  of  Fibroids  by  Radiotherapy. — During  the  past  15  years 
X-ray  has  been  employed  extensively  in  Germany  and  frequently, 
although  less  extensively,  in  this  country,  in  the  treatment  of  fibroids. 
More  recently,  radio-active  substances  have  been  used  for  the  same 
purpose.  The  year  before  the  war,  the  literature  was  fairly  teeming 
with  reports  of  both  methods  and  the  results  of  treatment.  The  sub- 
ject is  again  attracting  widespread  attention.  Treatment  by  raying 
with  either  method  may  be  definitely  indicated  in  certain  types  of 
tumors,  especially  when  the  patient  has  systemic  conditions  which 
centra-indicate  surgical  procedures.  The  field  is  not  wide,  however, 
since  it  is  not  applicable  to  the  one  type  of  growth  which  is  responsible 
for  the  most  troublesome  hemorrhage,  that  is,  submucous  growths, 
nor  to  tumors  with  marked  degenerations,  nor  to.  those  associated  with 
definite  inflammatory  conditions.  Since  we  cannot  with  certainty  dis- 
tinguish either  submucous  growths  or  early  cancerous  lesions,  nor 
recognize  all  cases  of  quiescent  pelvic  inflammation  associated  with 
fibroids  of  some  size,  it  follows  that  cases  should  be  carefully  selected 
for  treatment  with  the  rays,  and  the  method  should  not  be  followed  as 
a  routine. 

Roentgen-ray  Treatment  of  Fibroids. — Kronig  and  Gauss  were 
among  the  early  workers  who  employed  massive  doses  of  X-ray  in 
the  treatment  of  fibroids.  They  recognized  the  need  of  filtration  and 
the  value  of  crossfire.  In  the  years  which  have  passed  since  their  early 
work,  the  X-ray  apparatus  has  become  much  improved.  At  the  present 
time,  most  Roentgenologists  use  Coolidge  tubes,  with  water-cooling 
devices,  and  protect  the  skin  by  aluminum  filters,  3  or  4  millimeters 
thick.  There  are  two  methods  of  treatment,  the  intensive  method, 
by  which  a  single  large  dose  is  given  at  one  sitting;  and  the  fractional 
method  in  which  several  small  doses  are  given  during  a  period  ranging 
from  five  to  fifteen  weeks.  The  interval  between  the  treatments  in  the 
fractional  method  varies  from  one  to  three  weeks,  and  is  controlled  by 
the  patient's  tolerance  to  the  rays  and  the  urgency  of  the  symptoms. 
The  tumor  is  rayed  through  the  abdomen,  and  crossfire  is  given  over 
the  gluteal  and  sacral  regions.  The  ovaries  are  also  rayed  directly. 
The  body  surface  covering  the  pelvis  is  divided  into  a  number  of  small 


n6  PELVIC  NEOPLASMS 

fields,  each  of  which  is  treated  with  from  10  X  to  30  X  at  a  single 
sitting  (X  equals  the  erethymal  unit  for  skin).  The  total  dosage  varies 
according  to  the  size  of  the  tumor  and  the  technic  which  is  adopted. 
The  earlier  workers  used  large  doses  which,  however,  increases  the 
ever-present  chance  of  X-ray  burns.  Kronig  and  Gauss,  in  205  cases, 
used  an  average  dose  of  1480  X  for  a  total  of  five  weeks  treatment. 
Steiger,  in  Berne,  gave  from  500  X  to  2400  X  for  the  five  to  fifteen 
weeks  period  of  treatment.  The  majority  of  Americans  employ  smaller 
doses,  100  X  to  500  X,  since  they  hold  that  this  dosage  is  sufficient 
to  control  the  tumor  and  at  the  same  time  to  avoid  the  chance  of  serious 
burns,  or  toxic  constitutional  symptoms. 

METHOD  OF  ACTION. — There  is  a  marked  difference  of  opinion  concern- 
ing the  manner  in  which  X-ray  causes  changes  in  the  tumor.  Many,  among 
whom  we  may  cite  Meyer,  Cheron,  and  Grafenberg,  claim  that  there  is  a 
selective  destructive  action  of  the  X-ray  on  the  myoma  cell  which  atrophies 
in  consequence;  and  that  amenorrhea  does  not  result  because  of  ovarian 
changes.  Quite  naturally,  therefore,  we  should  expect  a  more  marked 
reduction  in  the  size  of  a  tumor  that  is  composed  chiefly  of  myomatous 
cells  than  in  growths  which  are  composed  principally  of  atrophic  fibrous 
tissue.  It  is  a  clinical  fact,  however,  that  hemorrhage  may  be  arrested 
without  marked  shrinking  of  the  tumor,  and  that  cases  presenting  this  phe- 
nomenon give  almost  without  exception  symptoms  of  ovarian  insufficiency 
such  as  the  flushes,  and  other  vasomotor  disturbances,  soon  after  beginning 
the  treatment.  These  findings  are  identical  with  those  seen  in  earlier  time 
when  treatment  of  fibroids  was  confined  chiefly  to  the  removal  of  the  ovaries 
without  attempts  to  remove  the  tumor.  For  these  reasons,  many  men 
believe  that  X-ray  acts  upon  fibroids  chiefly  by  killing  the  ovaries  and  in- 
ducing an  artificial  menopause. 

INDICATION  FOR  X-RAY  TREATMENT. — The  age  of  the  patient  is  often  an 
important  consideration  when  selecting  a  suitable  type  of  treatment.  X-ray 
is  not  the  method  of  choice  in  women  of  thirty-five,  or  less,  since  the  treat- 
ment is  very  likely  to  be  followed  by  a  permanent  amenorrhea.  If  the  pres- 
ervation of  ovarian  activity  is  an  important  consideration,  the  use  of  X-rays 
appears  to  be  contra-indicated,  although  some,  as  Frank,  and  Pfahler,  feel 
that  by  proper  dosage,  the  tumor- may  be  reduced  without  hurting  the  ovary 
to  the  extent  that  subsequent  pregnancy  is  impossible.  Intramural  tumors 
occasioning  hemorrhage  are  most  favorable  for  the  employment  of  X-ray, 
in  the  absence  of  pronounced  degenerative  changes  or  adnexal  inflammation. 
It  is  generally  agreed  tha4  submucous  or  subperitoneal  fibroids,  and  cervical 
and  broad  ligament  tumors  are  better  treated  by  surgery.  It  is  a  fact,  how- 
ever, that  by  the  ordinary  clinical  methods  of  examination,  we  cannot  dif- 
ferentiate between  interstitial  growths  and  certain  forms  of  submucous 
tumors.  The  size  of  the  tumor  is  also  an  important  consideration.  Fibroids 
reaching  to  the  level  of  the  umbilicus  are  so  often  associated  with  degenera- 
tions and  complications  that  the  employment  of  X-ray  should  be  restricted 


FIBROIDS  117 

to  tumors  which  occupy  the  pelvis  of  women  approaching  the  menopausal 
age,  or  those  in  whom  there  are  definite  centra-indications  to  surgery.  The 
fact  that  adenocarcinoma  of  the  body  of  the  uterus  occurs  so  frequently 
with  fibroids  (at  least  2  per  cent  of  cases)  demands  the  exclusion  of  this 
complication  before  X-ray  treatment  is  attempted. 

CONTRA-INDICATIONS. — Incarcerated  tumors,  submucous  or  subperito- 
neal  growths,  evidence  of  gangrenous  and  suppurative  processes,  the  presence 
of  adnexal  disease,  or  suspected  malignancy,  centra-indicates  its  employ- 
ment. A  rapidly  growing  tumor  is  usually  associated  with  either  a  benign 
or  a  malignant  degeneration,  and  surgical  removal  in  these  cases  is  better 
judgment.  We  have  frequently  emphasized  that  it  may  be  impossible  abso- 
lutely to  diagnose  the  presence  of  complications.  This  is  well  shown  by 
many  reported  cases.  Vineberg,  in  1915,  reported  a  multipara  of  28  pre- 
senting a  fibromyoma  associated  with  an  adenocarcinoma,  the  only  symptom 
of  which  was  prolonged  menstruation.  Personally,  we  have  seen  several 
such  cases  in  women  of  more  mature  years  (see  Figs.  32  and  36).  Macken- 
rodt,  in  1912,  reviewing  418  fibroids  treated  surgically,  claimed  that  only 
21  might  have  been  treated  properly  by  X-ray.  Tracy,  in  1915,  studying 
3,561  fibroid  operations,  felt  that  there  were  definite  contra-indications  to 
raying  in  33  per  cent  and  that  14  per  cent  would  have  died  if  that  were  the 
only  form  of  treatment.  Erdmann,  in  1917,  reported  330  hysterectomies 
for  fibroids  with  but  two  deaths  (6  per  cent  mortality).  Ten  of  the  cases 
in  this  series  presented  malignancy,  together  with  the  fibroid  so  that,  had 
X-ray  been  used  in  all  the  cases,  there  would  have  been  an  absolute  mortality 
from  unrecognized  malignancy  alone  of  3  per  cent. 

RESULTS  OF  X-RAY  TREATMENT. — The  results  are  usually  expressed  in 
terms  of  cure  of  the  symptoms.  Occasionally  the  size  of  the  tumor  is  men- 
tioned. Kronig  and  Gauss,  in  1913,  published  the  results  of  their  treatment 
of  205  cases  of  fibroids.  They  state  that  the  methods  was  applicable  to  85  per 
cent,  and  that  a  symptomatic  cure  was  obtained  in  100  per  cent.  They  did  not 
regard  adnexal  disease  as  a  centra-indication,  and  claimed  that  the  nervous 
symptoms  were  less  marked  because  the  internal  secretion  of  the  ovaries  was 
still  preserved.  Frank,  on  the  other  hand,  felt  that  only  5  per  cent  of  his 
series  of  fibroid  cases  should  be  treated  with  X-ray.  Eymer,  in  1912,  re- 
ported the  results  of  the  treatment  of  94  cases  of  fibroids  in  Heidelberg. 
Amenorrhea  was  obtained  in  49  cases  and  a  distinct  reduction  of  the  size 
of  the  tumors  was  noted  in  30  cases.  Steiger,  in  1915,  reported  his  results 
for  23  cases  which  ranged  in  size  from  a  man's  fist  to  a  man's  head.  Symp- 
tomatic cure  was  produced  in  85  per  cent.  Mohr  collected  from  the  German 
literature  796  fibroids  which  were  treated  by  X-ray.  At  the  time  of  the 
report,  127  were  still  under  treatment,  or  had  been  lost  to  view,  so  that 
his  report  was  based  on  the  study  of  669  cases.  Of  these,  376,  or  56.2  per 
cent,  were  considered  cured.  Amenorrhea  was  produced  in  97.1  per  cent 
of  this  group.  Oligorrhea  was  produced  in  .8  per  cent.  In  2.1  per  cent, 
there  had  been  no  complaint  of  menorrhagia.  Of  the  669  cases,  120,  or 


n8 


PELVIC   NEOPLASMS 


17.9  per  cent  were  improved.  In  37.5  per  cent  of  these,  amenorrhea  was 
desired  but  was  not  obtained,  although  oligorrhea  resulted  in  the  majority. 
Normal  menstruation  was  produced  in  10.8  per  cent  and  improvement  as 
far  as  hemorrhage  was  concerned,  resulted  in  51.7  per  cent.  In  this  series, 


FIG.  36. — ADENOCARCINOMA  OF  FUNDUS  WITH  FIBROIDS. 

1 1 .  i  per  cent  were  not  cured ;  recurrences  occurred  in  i  per  cent  and  deaths 
in  .29  per  cent.     His  table  is  of  interest  and  is  given  below. 

RECORD  OF  202  FIBROID  PATIENTS 


Age 

Number  cases 

Per  cent 

Cured 

Improved 

Not  cured 

30-40 
40-50 
Over  50 

28 
131 
43 

46.4 
80.9 
93-8 

42.9 
10 
4-7 

10.  7 
9.1 

2.3 

FIBROIDS  119 

SIZE  OF  TUMOR  IN  380  CASES 

Per  cent 

Unaltered    21.3 

Reduced    57.6 

Markedly  reduced 13.7 

Entirely  disappeared 5.3 

Subjective  sensation  of  diminution 8 

Increased    1.3 

Brettauer,  in  1918,  reported  the  results  of  33  fibroids  treated  by 
him  with  X-ray.  Permanent  amenorrhea  occurred  in  78  per  cent  and 
temporary  amenorrhea  in  22  per  cent.  The  tumors  had  varied  in  size, 
some  reaching  up  to  the  umbilicus.  In  almost  every  case,  he  found  a 
decided  reduction  in  size  and,  in  some  cases,  the  tumor  entirely  dis- 
appeared. Beclere,  in  1920,  recorded  his  results  for  400  cases.  Of 
these  cases,  25  per  cent  were  over  fifty  years  of  age;  n  per  cent  were 
under  forty ;  and  64  per  cent  were  between  forty  and  forty-nine  years. 
The  size  of  the  tumors  was  indicated  by  the  fact  that  85  per  cent  of 
them  were  palpable  through  the  abdomen  before  treatment.  He  used 
the  fractional  method  of  dosage.  The  hemorrhage  was  controlled  in 
60  per  cent  of  cases  by  twelve  to  fourteen  weekly  treatments.  A  meno- 
pause'was  produced  in  these  60  per  cent,  although  in  12  per  cent  the 
periods  were  suppressed  only  temporarily  and  returned  after  a  few 
months  or  years.  Beclere  states  that  the  growrth  of  the  tumor  was 
arrested  in  all  cases  and  was  usually  diminished  in  size.  Martindale, 
in  1920,  reports  the  results  of  X-ray  treatment  in  37  cases.  Amenor- 
rhea was  produced  in  30  of  these  and  was  not  produced  in  5.  The  other 
2  cases  already  had  amenorrhea.  The  number  of  treatments  necessary 
to  produce  amenorrhea  is  of  some  interest;  two  treatments  sufficed  in 
6  cases;  three  treatments  in  6;  four  treatments  in  n,  although  in  one 
of  these  the  periods  returned  at  ten  months  and  were  then  checked 
by  two  other  treatments;  five  treatments  were  necessary  in  6  cases, 
although  normal  menstruation  returned  in  i  of  these  after  seven 
months;  seven  treatments  w^ere  necessary  for  i  case. 

Amenorrhea  was  not  produced  in  i  case  after  five  treatments, 
although  normal  periods  resulted.  It  also  failed  in  cases  that  were 
treated  seven,  eight,  nine,  and  twelve  times  without  stopping  the 
bleeding.  One  case  had  had  amenorrhea  for  three  years  before  treat- 
ment. The  tumor  was  not  reduced  after  nine  treatments.  The  growth 
was  reduced  to  half  its  former  size  after  six  treatments  in  i  case;  after 
seven,  in  2  cases;  and  after  eleven,  in  2  cases. 

Personally,  we  see  several  cases  each  year  in  which  it  is  necessary 
to  remove  growths  which  do  not  respond  to  treatment.  On  the  con- 
trary, we  occasionally  see  astonishingly  good  results.  It  is  unfor- 
tunate, however,  that  the  literature  does  not  indicate  the  frequency  of 


120  PELVIC  NEOPLASMS 

burns  which  have  formed  such  an  unpleasant  and  troublesome  com- 
plication. 

Radium  Treatment  of  Fibroids. — The  physics,  method  of  screening, 
and  methods  of  application  have  been  described  under  radium  (q.  v., 
p.  120). 

INDICATIONS. — Indications  may  be  afforded  by  fibroids  which  cause 
bleeding  in  women  of  more  than  thirty-five  who  have  comparatively 
small  tumors,  or  in  younger  persons  in  whom  a  previous  myomectomy 
has  been  followed  by  recurrence  of  the  tumor.  Just  as  in  treatment 
with  X-ray,  the  best  results  are  to  be  expected  when  the  tumor  is  of 
the  interstitial  form.  It  is  extremely  important  that  cases  be  selected 
properly  for  treatment,  since  all  fibroids  should  not  be  treated  as  a 
routine,  either  by  surgery,  X-ray,  or  radium.  Tumors  the  size  of  a 
three-months  pregnancy,  or  smaller,  when  properly  selected,  respond 
well  to  radium.  The  hemorrhage  ceases,  or  is  controlled,  and  the 
growth  shrinks  in  size  when  the  treatment  is  well  chosen.  There  is  no 
evidence  to  justify  the  belief  that  large  fibroids  giving  pressure  symp- 
toms should  be  treated  in  this  manner. 

CONTRA-INDICATIONS. — The  chief  centra-indication  is  offered  by  the 
presence  of  old  pelvic  inflammatory  disease.  Cases  in  which  this  con- 
dition is  suspected  should  never  be  selected  for  radium  treatment, 
since  it  may  'light  up  the  old  process  and  cause  a  peritonitis.  Deaths 
from  this  cause  have  been  reported.  Submucous  and  subserous  tumors 
do  not  react  well  to  this  method.  This  is  extremely  unfortunate  since, 
as  has  been  repeatedly  stated,  submucous  fibroids  are  responsible  for 
the  great  majority  of  fibroid  cases  presenting  severe  and  protracted 
bleeding.  The  method  should  not  be  attempted  in  any  case  in  which 
degenerations  are  even  suspected,  since  radium  does  not  convert  such 
tumors  into  fibrous  connective  tissue,  but  increases  the  extent  of  the 
degeneration  and  favors  the  absorption  of  toxic  products  which  may 
give  severe  symptoms.  Death  has  occurred  in  such  cases  and  Clark 
emphasizes  the  fact  that  such  a  patient  may  serve  as  "a  sarcophagus 
for  her  decadent  tumor." 

While  carcinoma  of  the  uterine  body  does  not  centra-indicate  the 
use  of  radium,  it  is  a  fact  that  such  cases  do  better  with  surgical  pro- 
cedure. The  condition  can  be  diagnosed  with  certainty,  since  the 
careful  man  curettes  the  uterus  immediately  before  inserting  the 
radium.  If  he  studies  his  curettings,  the  condition  cannot  remain 
unsuspected.  The  presence  of  sarcomatous  degenerations  in  the 
fibroid  tumor  does  not  offer  a  centra-indication,  since  such  growths 
react  favorably  to  radium.  The  condition  may  not  be  diagnosed,  since 
sarcoma  of  this  type  does  not  early  invade  the  endometrium.  Tumors 
with  calcareous  degenerations  do  not  react  to  the  treatment. 

The  contra-indications  for  radium  treatment  of  fibroids  has  been 
summarized  by  Clark  as  follows : 


FIBROIDS  121 

1.  Tumors  larger  than  a  three-  or  four-months  pregnancy  should 
not  be  rayed  unless  there  are  decided  surgical  centra-indications,  such 
as  serious  heart  lesions,  diminished  renal  function,  or  other  constitu- 
tional defects  which  could  render  an  operation  a  serious  procedure. 

2.  All  tumors  associated  with  symptoms  indicative  of  inflammatory 
lesions,  because  of  the  many  reported  cases  in  which  a  flare-up  of  an 
old  inflammatory  lesion  has  formed  a  most  distressing  complication 
following  radium. 

3.  Patients  with   normal  or  slightly  increased   menstruation  who 
present  a  cachectic  appearance  and  toxic  symptoms  out  of  all  propor- 
tion to  the  amount  of  hemorrhage.    This  type  of  case  usually  indicates 
well-marked  degenerations  of 'the  tumor. 

4.  All  cases  in  which  there  are  symptoms  of  coexistent  abdominal 
lesions,  such  as  symptoms  of  cholecystitis,  appendicitis,  etc. 

In  spite  of  these  numerous  centra-indications,  excellent  results  will 
follow  the  radiation  of  cases  that  have  been  properly  selected,  that  is, 
tumors  of  small  size  with  hemorrhage  as  the  chief  symptom,  occurring 
in  middle-aged  women,  without  any  evidence  of  extensive  degenera- 
tions. 

METHOD  OF  ACTION. — In  contrast  to  the  X-ray,  radium  in  proper 
dosage  acts  chiefly  on  the  tissues  of  the  uterus  and  the  tumor  which 
it  converts  into  fibrous  tissue.  The  action  on  the  ovaries  is  less  marked 
and,  with  properly  controlled  treatment,  the  ovarian  function  need  not 
be  injured.  The  tumor  is  reduced  in  size  in  nearly  all  cases. 

TECH  NIC. — The  technic  is  identical  with  that  for  a  curettage.  The 
labia  are  shaved  and  the  vagina  is  cleaned  with  soap  and  water,  ^  per 
cent  lysol  solution,  and  60  per  cent  alcohol.  It  is  not  necessary  to 
catheterize  if  the  patient  voids.  The  rectum  should  be  emptied  with 
an  enema  several  hours  before  the  operation.  Anesthesia  is  usually 
necessary.  Nitrous  oxid  and  oxygen  meets  all  indications.  The  cervix 
is  exposed  by  means  of  vaginal  specula  and  is  grasped  and  steadied 
with  a  tenaculum,  while  the  cervix  is  dilated  to  admit  the  capsule  con- 
taining the  radium.  The  uterus  is  then  curetted,  and  the  tissues  which 
have  been  removed  are  carefully  inspected  to  be  sure  that  carcinoma 
is  not  present.  The  radium  is  then  inserted.  It  may  be  used  either  as 
a  salt  or  emanation.  The  arrangement  of  the  capsule  depends  largely 
upon  the  size,  length,  and  position  of  the  uterine  cavity.  In  general, 
the  radium  should  be  applied  over  as  much  of  the  uterine  surface  as 
seems  feasible.  Four  tubes  of  radium  mounted  tandem  in  suitable 
capsules  of  brass  or  silver,  sufficient  to  exclude  the  majority  of  the 
Beta  rays,  will  suffice  for  the  largest  tumors  in  which  treatment  is  indi- 
cated. Ordinarily,  two  bars  suffice.  They  should  be  included  in  a 
heavy  tube  of  black  rubber  and  inserted  directly  into  the  uterus.  The 
vagina  is  then  packed  with  gauze. 

DOSAGE. — The  dosage  depends  upon  the  age  of  the  patient  and  whether 


122  PELVIC  NEOPLASMS 

a  menopause  is  desired  or  menstruation  is  to  be  preserved.  While  not 
definitely  standardized,  women  under  thirty-five  should  have  about 
400  mg.  or  me.  hours  for  their  initial  dose.  It  is  better  to  give  too 
small  rather  than  too  large  a  dose  at  the  first  treatment.  Women 
thirty-five  or  more,  may  be  given  a  larger  dose  at  the  first  treatment; 
50  mg.  or  me.  for  twenty-four  hours  meets  with  the  approval  of  the 
majority  of  workers.  We  see  no  objection  to  giving  100  mg.  or  me. 
for  twelve  to  ftfteen  hours. 

RESULTS. — Kelly,  in  1914, -reported  his  results  with  the  radium  treat- 
ment of  21  fibroids  ranging  in  size  from  a  two-months  pregnancy  to 
growths  as  high  as  the  umbilicus.  The  ages  range  .between  thirty- 
three  and  fifty-nine  years.  The  tumor  shrunk  in  size  or  disappeared 
in  each  case  and  complete  amenorrhea  was  obtained  in  16  cases.  He 
was  unable  to  insert  the  radium  in  the  uterus  in  I  case  which  could  not, 
in  consequence,  be  treated.  In  1918,  Kelly  reported  his  results  for  211 
cases  of  uncomplicated  fibroids  of  varying  size.  In  this  series,  87 
women  were  cured  and  the  tumors  disappeared  or  became  insignificant 
in  size.  Fourteen  were  well  but  failed  to  report  for  subsequent  exam- 
ination. The  tumor  reduced  in  size  in  62  cases  but  since  two  years  had 
not  elapsed  since  the  last  treatment,  the  investigator  felt  the  interval 
was  too  short  to  draw  any  conclusions.  Two  cases  presenting  compli- 
cations were  not  improved  by  the  treatment.  Eight  did  not  stay  cured 
and  were  subsequently  operated.  There  were  2  deaths  following  treat- 
ment. His  method  consisted  in  the  application  of  from  300  to  500  mcs. 
maintained  in  place  for  three  hours. 

Stacy  reports  a  series  of  600  cases  treated  by  radium  at  the  Mayo 
Clinic.  She  divides  the  material  into  two  classes,  according  to  their 
age.  There  were  122  women  under  thirty-five  of  whom  19  were 
twenty-five  or  under.  Small  initial  doses  were  given  to  these,  aiming 
to  control  the  symptoms  but  not  to  stop  menstruation.  The  average 
dose  for  this  group  of  cases  was  about  300  mg.  hours.  Menorrhagia 
was  controlled  by  one  treatment  in  55.6  per  cent  of  cases.  A  second 
treatment  was  necessary  in  17  cases.  A  larger  dose  was  given  to  the 
women  of  thirty-five  and  over,  although  it  must  be  classed  as  small. 
In  349  patients,  a  second  treatment  was  necessary  in  64  and  a  subse- 
quent operation  was  done  in  20.  Curtis,  in  1920,  briefly  summarizes 
his  results  in  the  treatment  of  62  fibroid  tumors  in  which  50  mgs.  of 
radium  were  applied  for  approximately  twenty-four  hours.  He  states 
that  the  hemorrhage  always  stopped  but  that  the  decrease  in  size  of  the 
tumors  varied  considerably.  Subsequent  hysterectomy  was  necessary 
a  few  times  because  of  symptoms  from  preexisting  pressure  or  ad- 
hesions. This  series  comprises  selected  cases  in  which  the  tumors 
were  of  small  size  and  which  gave  symptoms  of  hemorrhage.  Clark, 
in  1920,  states  that  in  a  series  of  over  150  cases  selected  for  radium 
treatment,  the  results  in  4  were  not  sufficient  to  satisfy  them,  or  him- 


FIBROIDS  123 

self,  and  he  subsequently  did  a  hysterectomy.  Two  others  were  oper- 
ated on  at  other  clinics.  In  all  others,  the  results  were  most  satisfac- 
tory and  recovery  ensued  without  complications  in  all  except  one. 

Radical  Treatment. — There  is  not  yet  complete  agreement  as  to  the 
extent  to  which  radical  treatment  should  be  employed.  The  view  that 
we  should  remove  all  fibroids  unless  there  are  contra-indications  to 
surgical  treatment  is  combated  by  many  excellent  results  which  have 
been  obtained  by  treatment  with  X-ray  or  radium.  It  is  a  fact,  how- 
ever, that  no  treatment  which  has  yet  been  advanced  is  completely 
free  from  mortality,  even  X-ray  or  radium.  Malignant  degeneration 
occurs  so  frequently  in  cases  where  its  presence  has  not  been  even 
suspected  that  the  physician  should  bear  in  mind  the  fact  that  the  removal 
of  the  uterus  and  tumor  alone  offers  absolute  chance  of  cure.  The 
advocates  of  operation  in  all  cases  call  attention  to  the  point  that  the 
removal  of  small  tumors  is  attended  with  a  very  small  mortality,  while 
that  of  the  larger  growths  is  very  low  in  proportion  to  the  size  of  the 
tumor.  The  opponents  of  this  view  state  that  the  mortality  from  non- 
operative  treatment  (X-ray  and  radium)  is  much  less  than  that  follow- 
ing operation  and  believe  that  the  indications  for  removal  should  be 
restricted  only  to  growths  which  are  causing  symptoms  and  in  which 
the  tumor  is  large  and  rapidly  growing.  The  common  sense  of  the 
matter  is  that  cases  should  be  considered  individually  for  the  various 
treatments.  Large  growths  in  comparative  youth  should  be  removed 
early  while  small  growths  in  women  approaching  the  menopause  may 
properly  be  treated  with  X-ray  or  radium,  if  the  diagnosis  of  malig- 
nancy has  been  absolutely  excluded.  The  fact  that  fibroids  may  kill 
has  been  shown  in  the  section  on  prognosis  without  operation  (see 
page  171).  Even  if  we  grant  that  the  figures  of  Noble  and  Winter  are 
too  high  for  present  consideration,  since  they  represented  conditions 
which  obtained  before  fibroids  were  removed  early,  we  must  admit 
that  fibroids  may  kill  through  degeneration,  and  that  many  women 
escape  this  danger  only  to  undergo  invalidism.  The  surgeon  must  be 
guided  in  his  treatment  by  his  results  and  by  the  mortality  which  fol- 
lows his  own  treatment.  Nearly  all  now  recognize  that  good  results 
cannot  be  obtained  by  emergency  operations  in  extremis  and  that  a  proper 
surgical  technic  has  been  developed  so  that  operations  may  come  into 
competition  with  nonsurgical  measures. 

POSITIVE  INDICATIONS  FOR  OPERATION. — The  more  important  degenera- 
tions indicate  operation  in  cases  presenting  symptoms,  or  in  tumors  of 
considerable  size  without  symptoms.  Olshausen,  a  generation  ago, 
stated  that  degenerations  do  not  occur  in  more  than  5  per  cent  of  cases,  yet 
the  careful  work  of  Winter  has  shown  that  sarcoma  alone  occurs  in 
nearly  5  per  cent  of  growths  of  average  size.  The  frequency  with 
which  carcinoma  occurs  with  fibroids  is  emphasized  by  nearly  all  recent 
investigators.  If  one  observer,  as  Winter,  has  proved  that  malignancy 


124  PELVIC  NEOPLASMS 

occurs  in  5  per  cent  of  cases,  it  is  useless  to  cite  a  long  list  of  authors- 
whose  proportions  of  malignancy  are  smaller,  especially  if  we  know 
that  the  routine  examinations  of  many  of  the  series  could  be  subjected 
to  criticism.  Hemorrhage  that  does  not  respond  to  other  measures 
demands  operation  before  the  patient's  chance  is  impaired  by  the 
sequelae  of  marked  anemia.  The  large  number  of  serious  secondary 
complications  in  the  adnexa  and  the  actual  presence  of  a  growing 
tumor  form  indications  which  cannot  be  disputed.  Yet  one  should 
carefully  review  the  various  factors  of  age,  social  state,  and  other 
similar  points  before  deciding  in  favor  of  an  operation  which  is  not 
demanded  by  conditions  which  threaten  life  or  promise  invalidism. 
We  should  bear  in  mind,  however,  if  the  case  be  elected  to  wait  for 
the  menopause,  that  this  condition  is  usually  greatly  postponed  in 
fibroid  cases  even  well  into  the  middle  of  the  fifth  decade,  even  in 
tumors  of  comparatively  small  size.  The  physician  who  does  surgery 
only  occasionally  should  remember  that  there  is  always  mortality 
attending  the  removal  of  fibroids,  and  that  it  is  likely  to  be  much 
greater  in  his  hands  than  in  those  of  an  expert.  Primary  operations 
are  not  practiced  by  most  conservative  men  in  more  than  50  per  cent 
of  the  cases  which  come  under  his  observation. 

CONTRA-INDICATIONS  TO  OPERATION. — These  are  the  same  as  for  any 
other  surgical  procedure.  No  operation  should  be  undertaken  unless 
the  patient  has  been  subjected  to  a  most  careful  routine  examination 
in  which  all  necessary  tests  are  made  to  establish  the  function  of  the 
heart,  lungs  and  kidneys.  Anemia  may  offer  a  centra-indication.  We 
do  not  operate  cases  with  hemoglobin  of  less  than  50  per  cent  until  they 
have  been  treated  with  blood  transfusion. 

The  surgical  procedures  at  the  present  time  are  myome'ctomy  and  hys- 
terectomy, and  there  has  been  much  discussion  as  to  the  relative  advantages 
of  each.  There  is  no  doubt  but  that,  from  the  standpoint  of  pure 
theory,  myomectomy  has  many  advantages  of  a  conservative  nature  if 
done  on  young  women.  For  example,  it  leaves  them  often  able  to 
bear  children  and  avoids  the  induction  of  an  artificial  menopause, 
which  so  often  entails  many  distressing  nervous  complications.  It 
should  not  be  performed  on  women  more  than  thirty-five  years  of 
age,  since  experience  has  shown  that  secondary  operations  are  often 
necessary  subsequent  to  myomectomy.  It  should  be  the  surgeon's  aim 
to  accomplish  all  that  is  necessary  at  a  single  operation.  Myomectomy 
does  not  seem  justifiable  if  there  are  multiple  fibroids  of  large  size 
imbedded  in  the  uterus.  These  is  always  a  question  as  to  what  the 
scar  will  stand  in  case  of  subsequent  pregnancy.  Tubal  or  ovarian 
disease  also  centra-indicate  myomectomy  as  does  any  other  condition 
which  is  a  barrier  to  pregnancy.  Myomectomy  should  not  be  attempted 
if  the  growth  is  of  large  size,  because  of  the  considerable  chance  of 
malignant  changes.  Moreover,  the  removal  of  the  larger  tumor  in  no 


FIBROIDS  125 

way  interferes  with  the  development  subsequently  of  the  smaller 
growths  which  may  be  so  readily  overlooked  at  time  of  operation. 
Quite  to  the  contrary,  in  fact,  since  the  latter  grow  frequently  to  consider- 
able size  because  of  the  improvement  in  the  uterine  circulation  follow- 
ing myomectomy  and  occasionally  demand  removal  by  secondary 
operation.  Finally,  multiple  myomectomy  may  be  contra-indicated 
when  it  appears  impossible  satisfactorily  to  peritonealize  the  numerous 
incisions.  If  surgery  is  to  be  used  for  the  treatment  of  chronic  condi- 
tions which  do  not  uniformly  kill,  the  operator  must  see  that  his  technic 
does  not  excite  secondary  symptoms  more  severe  and  dangerous  than 
those  which  constituted  the  first  complaint. 

The  older  literature  shows  that  myomectomy  was  followed  by  a 
mortality  greater  than  that  attending  hysterectomy.  Hunner,  in  1903, 
reported  a  mortality  of  5  per  cent  in  100  cases  of  myomectomy  in 
Kelly's  clinic.  Winter,  in  1904,  compiled  451  cases  of  Hofmeier,  von 
Rosthorn,  Martin,  Olshausen,  Schauta,  and  Zweifel  and  found  a  mor- 
tality of  9.8  per  cent  in  contrast  with  a  4.5  per  cent  mortality  of  a  large 
series  which  the  same  men  had  treated  by  supravaginal  hysterectomy. 
Kelly,  in  1907,  reported  a  mortality  of  4.5  per  cent  for  306  myomec- 
tomies  in  contrast  with  the  mortality  of  3.1  per  cent  for  691  hysterec- 
tomies. Kelly  and  Cullen,  in  1909,  give  a  mortality  of  5.4  per  cent  for 
296  abdominal  myomectomies.  Fifty  per  cent  of  these  deaths  were 
caused  by  intestinal  obstruction,  peritonitis,  or  both.  Subsequent 
operation  was  necessary  in  18  of  the  280  cases  who  survived  the 
primary  operation.  The  same  authors  obtained  a  mortality  of  6  per 
cent  in  84  vaginal  myomectomies.  They  followed  48  of  their  surviving 
cases  and  found  that  subsequent  hysterectomy  was  necessary  in  2  of 
them  and  that  carcinoma  developed  in  i  other.  The  primary  mortality 
for  their  series  of  901  abdominal  hysterectomies  was  5.5  per  cent  and 
no  mortality  in  24  cases  treated  by  vaginal  hysterectomy.  The  earlier 
cases  of  the  series  were  responsible  for  comparatively  high  mortality, 
since  the  cases  operated  for  two  and  a  half  years  before  the  report 
were  done  with  less  than  I  per  cent  mortality. 

These  figures  give  the  mortality  of  an  older  period.  With  improve- 
ment of  technic,  better  conditions  obtain.  Bad  results  were  often 
reported  when  myomectomies  were  done  for  large  tumors.  This  may 
have  been  due  to  tying  too  tightly  the  sutures  which  effaced  the  cavity 
caused  by  the  removal  of  the  tumor.  There  is  a  striking  resemblance 
between  the  uterine  muscle  which  has  hypertrophied  in  response  to  the 
stimulus  presented  by  a  fibroid  tumor  and  the  uterine  musculature  in 
pregnancy.  Just  as  in  cesarean  section,  we  must  expect  some  bad 
results  in  myomectomy,  since  the  sutures  are  placed  in  a  uterine  mus- 
culature which  is  undergoing  involution.  Bad  results  follow  improper 
peritonealization.  The  illustrations  in  textbooks  show  this  in  a  striking 
way;  a  row  of  knots  with  the  long  ends  of  catgut  projecting  beyond 


126  PELVIC  NEOPLASMS 

the  peritoneal  surface  of  the  uterus  is  invariably  shown.  Nature 
always  covers  these  surfaces  with  adhesions.  A  proper  peritoneal 
cover  is  shown  in  Fig.  40  (q.v.). 

During  the  last  few  years,  it  has  been  conclusively  proved  that  myo- 
mectomy  should  carry  a  risk  no  greater  than  that  of  supravaginal  hys- 
terectomy. Mayo,  in  his  report  in  1910,  gave  the  mortality  of  2.3  per 
cent  for  1,244  myomectomies  in  which  820  coincident  operations  were 
done.  The  mortality  for  900  supravaginal  hysterectomies  was  2.3  per 
cent.  Essen-Moeller,  in  1917,  obtained  nearly  identical  percentages 
of  death  in  myomectomy  and  supravaginal  hysterectomy.  Mayo,  in 
1917,  reports  504  consecutive  myomectomies  with  four  deaths  (0.8  per 
cent).  Five  of  the  cases  required  subsequent  hysterectomies.  Recent 
literature  indicates  that  the  mortality  attending  surgical  treatment  of 
fibroids  is  now  well  under  2  per  cent.  Deaver,  in  1916,  reports  750 
cases  operated  with  1.73  per  cent.  Broun,  in  1918,  records  1,500  cases 
treated  surgically  with  1.8  per  cent  mortality.  There  were  262  cases 
operated  at  the  Woman's  Hospital  in  New  York  during  1918,  with  4 
deaths  (1.5  per  cent). 

Myomectomy. — Myomectomy  may  be  performed  through  an  ab- 
dominal or  vaginal  incision.  Unless  there  are  compelling  reasons  why 
the  vaginal  route  should  be  used,  the  method  of  choice  is  through  an 
abdominal  incision. 

Preliminary  to  either  method,  the  vulva  should  be  shaved  and  the 
vagina  washed  out,  with  soap  and  water,  lysol  and  70  per  cent  alcohol. 
In  case  the  operation  is  to  be  done  through  the  abdomen,  the  vagina 
should  be  packed  with  a  long  strip  of  sterile  gauze. 

ABDOMINAL  MYOMECTOMY. — There  are  a  number  of  points  in  technic 
which  merit  especial  consideration.  The  exposure  should  be  adequate, 
so  that  the  work  may  be  done  in  place  and  without  forcibly  dragging 
the  uterus  out  of  the  abdominal  incision.  The  surgeon  should  avoid  all 
unnecessary  trauma,  since  the  subsequent  health  of  the  patient  will  be 
largely  determined  by  the  presence  or  absence  of  abdominal  adhesions 
following  operation.  In  this  connection,  it  may  pay  to  review  certain 
errors  in  the  usually  accepted  technic.  Many  men  routinely  suture  the 
peritoneum  to  the  skin  in  order  to  limit  the  bruising  of  the  abdominal 
fat  during  the  operation.  The  peritoneum  is  infinitely  more  sensitive 
to  trauma  than  is  the  fat,  and  injuries  resulting  from  bruising  it  entail 
far  more  serious  consequences.  The  flap  of  the  peritoneum  that  is 
pulled  up  to  the  skin  must  suffer  serious  abrasions  from  the  tugging  of 
the  retractors  and  the  handling  that  is  necessary  in  all  abdominal 
operations.  At  the  end  of  the  operation,  these  abraded  areas  are 
usually  turned  back  into  the  abdomen  and  are  not  made  extraperitoneal 
in  closing  the  peritoneum.  Adhesions  of  the  omentum  or  bowel  almost 
uniformly  result.  There  is  also  the  very  great  possibility  that  the 
visceral  peritoneum  is  injured  by  the  abdominal  packs  which  are  used 


FIG.  37.— ABDOMINAL  MYOMECTOMY.    Fixing  the  tumor.     (Doederlein-Kronig.) 

127 


i28  PELVIC  NEOPLASMS 

to  hold  back  the  intestines  from  the  field  of  operation.  Any  gauze, 
even  though  wet,  will  cause  the  denudation  of  the  delicate  peritoneal 
cells.  At  the  close  of  an  hour's  operation,  one  may  see  the  imprint  of 
the  gauze  mesh  upon  the  bowel  peritoneum.  There  is  also  an  enormous 
intraperitoneal  extravasation  of  serum.  Our  experience  has  shown 
that  a  large,  heavy  rubber  dam  is  less  irritating  than  the  wet  gauze 
packing  and  is  to  be  preferred  for  that  reason. 

There  is  also  much  to  say  as  to  the  type  of  the  incision.  In  our 
minds,  nothing  equals  the  midline  incision,  since  you  cut  through  a 
minimum  of  nerves  and  vessels  and  have  the  best  opportunity  of 
obtaining  a  firmly  closed  incision.  Especially  is  this  true  if  the  median 
edges  of  the  recti  muscles  are  turned  from  their  sheaths  to  create  broad 
areas  for  apposition.  Many  surgeons  advise  an  incision  in  the  mesial 
edge  of  the  rectus  muscle.  This,  in  our  judgment,  is  an  error.  Nearly 
all  women  who  have  borne  children  have  a  diastasis  of  the  recti  which 
frequently  amounts  almost  to  a  hernia.  The  diastasis  cannot  be  closed 
if  one  uses  a  rectus  incision.  The  nerves  of  the  muscle  are  also  severed 
by  the  rectus  incision  and  are  far  more  likely  to  favor  the  production  of 
abdominal  adhesions  as  has  been  shown  by  the  experimental  work  of 
Sweet,  Cheney  and  Wilson.  These  observers  found  that  definite 
mechanical  trauma,  such  as  scrubbing  the  peritoneum  underlying  the 
rectus  muscle  in  dogs,  was  not  uniformly  followed  by  firm  bands  of 
adhesions  except  when  the  abdominal  approach  was  made  by  a  rectus 
incision  and  the  consequent  injury  of  nerves  of  the  abdominal  wall. 

Fixed  mechanical  abdominal  retractors  are  far  better  than  the  hand 
retractors,  since,  when  they  are  locked,  they  hold  the  edges  firmly 
apart,  and  Cannot  move  to  and  fro  to  cause  peritoneal  abrasions  as  must 
the  hand  retractors  which  are  held  by  assistants.  Nor  do  the  edges  of 
the  blades  impinge  in  the  neighborhood  of  the  vessels  of  the  abdominal 
wall  to  traumatize  and  favor  thrombosis  and  embolism  as  the  hand 
retractors  always  do. 

The  technic  of  abdominal  myomectomy  depends  largely  upon  the  site 
and  form  of  the  growth  which  is  to  be  removed. 

TECHNIC  IN  SUBPERITONEAL  PEDUNCULATED  FIBROIDS. — The  growth  is 
seized  by  a  tenaculum  and  an  incision  is  made  through  the  peritoneal  cover- 
ing at  the  uterine  margin  of  the  pedicle.  The  peritoneum  is  then 
stripped  backward  as  a  cuff  and  the  exposed  base  of  the  pedicle  is 
sutured  as  may  be  necessary  to  control  all  bleeding  with  one  or  two 
plain  catgut  sutures.  The  tumor  is  then  cut  away  externally  to  the 
ligatures.  When  the  tumor  has  a  broad,  pedicled  base,  one  should  plan 
the  incision  so  that  there  results  a  craterlike  cavity  after  the  tumor  is 
removed,  which  can  be  closed  without  tension  by  a  continuous  running 
plain  catgut  suture  placed  deeply.  The  peritoneal  cuff,  after  the 
removal  of  either  type  of  tumor,  is  inverted  and  closed  with  fine  No.  oo 
plain  catgut  mounted  on  a  curved  intestinal  needle,  so  that  there  is  no 


FIG.  38. — ABDOMINAL  MYOMECTOMY.    Shelling  out  the  tumor.     (Doederlein-Kronig.) 


129 


I30 


PELVIC  NEOPLASMS 


exposure  of  any  raw  surfaces  and  only  the  final  knot  lies  upon  the 
serous  surface. 

TECHNIC  IN  SUBPERITONEAL  SESSILE  AND  INTERSTITIAL  FIBROIDS.— 
When  there  are  a  number  of  growths  to  be  removed  from  the  uterine 
body,  the  incision  should  be  planned  so  that  they  shall  be  as  few  as 
possible  and  shall  run  in  the  same  direction.    The  incision  is  then  made 


FIG.  39. — ABDOMINAL  MYOMECTOMY.     Closing  the  cavity  in  layers  to  secure  perfect  approxi- 
mation, 

through  the  capsule  until  the  tumor  or  tumors  lie  exposed.  The  growth 
is  now  seized  with  a.  tenaculum  and  the  opening  in  the  capsule  is 
enlarged  sufficiently  to  allow  the  removal  of  the  tumor  (Fig.  37).  The 
tumor  is  separated  from  its  bed  by  blunt  dissection,  which  usually  occa- 
sions no  difficulty  (Fig.  38).  Very  rarely  it  may  be  necessary  to  cut  it  with 
scissors.  One  should  exert  every  care  so  that  the  uterine  cavity  will 


FIBROIDS  I3i 

not  be  opened.  In  case  there  is  much  hemorrhage,  the  margins  of  the 
uterine  wound  are  widely  retracted  with  narrow  retractors  or  by  single 
tenacula.  Any  bleeding  vessels  are  transfixed  and  tied  with  ligatures 
mounted  on  small  needles.  The  raw  bed  of  the  fibroid  is  now  closed 
without  tension  by  continuous  No.  I  plain  catgut  sutures  (Fig.  39).  The 
peritoneal  edge  of  the  incision  is  inverted  with  a  No.  oo  plain  catgut  suture 


FIG.  40. — ABDOMINAL  MYOMECTOMY.     Proper  pentonealization  obtained  by  approximating 
the  serous  surfaces  with  fine  plain  catgut  sutures 

mounted  on  an  intestinal  needle  (Fig.  40).  Very  rarely  there  is  consider- 
able hemorrhage  from  the  bed  of  the  tumor.  If  this  cannot  be  checked  by 
hot  packs,  it  is  usually  controlled  by  figure  8  sutures  tied  only  as  firmly 
as  is  necessary  to  arrest  the  bleeding.  It  is  not  well  ever  to  tie  sutures 
in  myomectomy  operations  tighter  than  is  absolutely  necessary,  since 
they  readily  cut  through  after  the  closure  of  the  operation.  If  the  hemor- 


i3 2  PELVIC  NEOPLASMS 

rhage  cannot  be  checked  in  this  manner,  an  assistant  should  make  pressure 
on  the  cardinal  vessels  to  stop  the  bleeding. 

This  operation  may  be  employed  in  cases  which  have  several 
fibroids  in  the  uterus  lying  close  together.  Yet  multiple  myomectomy 
is  not  usually  advisable,  since  it  is  extremely  likely  that  other  fibroids 
not  exposed  to  view  may  develop  after  the  operation  and  later  present 
their  symptoms.  Very  large  fibroids,  even  when  single,  should  not  be 
removed  by  myomectomy,  since  a  good  closure  cannot  always  be 
obtained  without  extreme  distortion  of  the  uterus.  Myomectomy 
should  never  be  performed  if  there  is  chance  that  the  uterine  cavity  is 
infected.  The  patient  may  lose  a  considerable  amount  of  blood  during 
a  myomectomy  for  a  large  growth,  and  the  uterus  is  not  likely  to  be  a 
satisfactory  organ  if  pregnancy  should  subsequently  result. 

Very  rarely  it  may  be  found  advantageous  in  performing  myomec- 
tomy to  split  the  uterus  in  halves  at  the  beginning  of  the  operation, 
cutting  down  directly  through  the  tumor.  The  edges  of  the  wound  are 
then  widely  separated  and  the  divided  growth  is  shelled  from  out  its 
bed.  This  method  is  preferable  to  the  former  in  difficult  cases,  and 
especially  in  those  in  which  the  uterus  is  impacted  in  the  pelvis.  Nearly 
all  operators,  however,  advocate  a  supravaginal  hysterectomy  in  cases 
requiring  so  great  a  wound  in  the  uterine  muscles. 

TECHNIC  IN  INTRALIGAMENTOUS  FIBROIDS. — Myomectomy  is  suitable 
only  for  growths  that  are  so  small  that  they  can  be  removed  with  little 
bleeding  and  trauma.  Large  intraligamentous  tumors  should  not  be 
removed  in  this  manner  unless  the  pedicle  is  very  small.  When  these 
tumors  present  complicated  relationships  with  surrounding  structures, 
as  is  usually  the  case,  hysterectomy  is  the  method  of  choice.  There  is 
apt  to  be  less  bleeding  after  hysterectomy  than  after  myomectomy,  and 
far  less  chance  of  injuring  the  ureters  and  pelvic  veins.  When  the 
tumor  has  been  dissected  from  the  areolar  tissue,  the  incision  should  be 
covered  by  the  excess  of  loose  peritoneum,  so  that  there  may  be 
smooth  peritoneal  surfaces  and  no  displacement  from  the  normal  uter- 
ine position.  The  round  ligaments  often  can  be  utilized  for  making  a 
smooth  peritoneal  covering  and  for  holding  the  uterus  in  place. 

VAGINAL  MYOMECTOMY. — Vaginal  myomectomy  is  often  advocated  by 
surgeons  who  have  safely  removed  large  tumors  through  the  vagina. 
Yet,  as  a  rule,  the  results  which  they  have  obtained  merely  demon- 
strate the  possibilities  of  the  operation,  not  its  relative  desirability. 
Since  the  operative  technic  of  the  abdominal  operation  has  become 
fairly  standardized,  the  removal  of  large  tumors  is  more  safe  through 
the  abdomen  than  through  the  vaginal  orifice.  Vaginal  myomectomy 
is  preferable  for  the  removal  of  tumors  which  present  in  the  uterine 
cavity,  especially  for  submucous  fibroids  which  have  become  infected. 
There  are  numerous  reports  in  the  medical  literature  of  tumors  weigh- 
ing as  much  as  six  or  eight  pounds  that  have  been  removed  by  this 


FIBROIDS  133 

means.  The  usual  limitation  of  size  is  that  of  the  fetal  head,  or  roughly 
speaking,  a  tumor  10  or  12  centimeters  in  diameter.  Such  growths, 
however,  should  be  reduced  in  size  if  they  are  to  be  removed  without 
great  trauma. 

Vaginal  myomectomy  is  indicated  for  the  removal  of  (a)  small  fibroid 
polyps  contained  in  the  cavity  of  the  uterus  or  projecting  through  the  cer- 
vical canal  down  into  the  vagina ;  these  usually  cause  little  difficulty  and  can 
be  snipped  off  with  the  scissors;  (b)  larger  submucous  fibroids  which  are 
contained  in  the  cavity  of  the  uterus  or  undergo  expulsion  into  the  vagina, 
especially  when  they  are  single  and  not  of  great  size;  these  growths  are 
usually  infected  and  removal  should  not  be  attempted  until  the  field  of 
operation  has  been  disinfected  in  a  satisfactory  manner  by  a  rather  extended 
period  of  local  treatment  with  irrigations,  unless  hemorrhage  and 
anemia  are  prominent  symptoms. 

Vaginal  myomectomy  may  be  used  to  remove  (c)  cervical  fibroids  of 
moderate  size  which  can  usually  be  reached  after  exposure  has  been  obtained 
by  colpotomy  or  hysterotomy;  (a?)  subperitoneal  fibroids  of  moderate  size 
which  are  situated  on  either  the  anterior  or  posterior  wall;  (e)  single  intra- 
mural fibroids  of  moderate  size,  especially  when  situated  on  the  anterior 
wall. 

Indication  may  be  afforded  in  fat  women  because  of  their  size,  although, 
as  a  rule,  the  last  three  groups  of  tumors  are  removed  more  satisfactorily 
after  laparotomy,  since  proper  peritoneal  cover  can  be  made  in  a  better 
manner. 

TECH  NIC  IN  PEDUNCULATED  SUBMUCOUS  FIBROIDS. — The  tumor  may 
be  removed  through  the  dilated  cervix,  or  after  the  cervix  has  been 
split  by  means  of  a  hysterectomy.  The  latter  is  the  method  of  choice 
in  case  the  polyp  does  not  project  through  the  external  os. 

A  tumor  which  projects  through  the  dilated  os  is  seized  with  the 
forceps  and  twisted  off  from  its  attachment,  or  else  its  pedicle  is 
snipped  with  the  scissors.  This  should  not  be  attempted  until  the  condition 
of  the  growth  and  its  pedicle  has  been  ascertained  by  inspection  or 
careful  palpation,  since  malignant  changes,  unfortunately,  are  common. 
The  cavity  of  the  uterus  is  then  packed  after  it  has  been  swabbed  with 
half  tincture  of  iodin.  The  pack  is  removed  in  twenty-four  hours. 

If  the  polyp  does  not  project  through  the  external  os,  the  tumor 
may  be  removed  in  a  similar  manner  after  exposure  has  been  obtained 
by  hysterotomy.  At  a  rule,  the  anterior  hysterotomy  is  preferable. 
The  cervix  is  seized  by  its  upper  central  margin  with  two  tenacula,  and 
an  incision  is  made  on  the  anterior  vaginal  wall  transversely  and  below 
the  level  of  the  bladder.  The  bladder  is  now  separated  from  the 
cervical  wall  as  high  as  the  level  of  the  internal  os  by  means  of  dissect- 
ing scissors.  The  anterior  lip  of  the  cervix  is  now  divided  in  the  mid- 
line.  As  a  rule,  the  incision  bleeds  but  little  and  the  oozing  can  readily 
be  controlled  by  traction  of  tenaculae  applied  to  each  side  of  the  in- 


134 


PELVIC  NEOPLASMS 


cision.  In  the  same  way,  the  uterus  is  brought  down  and  into  view. 
If  the  tumor  is  of  comparatively  small  size,  it  may  be  removed  without 
reduction  of  its  size.  Larger  growths  should  be  reduced  in  size  by  a 
method  shown  in  Fig.  41.  When  the  pedicle  is  reached,  it  may  be 
ligated  and  divided  with  the  scissors.  Torsion  is  frequently  helpful  in 
controlling  the  bleeding.  The  pedicle  should  not  be  divided  too  close 


FIG.  41. — VAGINAL  MYOMECTOMY.     Incisions  for  reducing  the  bulk  of  the  tumor. 

to  the  wall,  since  the  uterus  often  prolapses  with  the  tumor  and  the 
incision  unwittingly  may  extend  well  into  the  uterine  body.  As  in  the 
previous  operation,  the  abraded  area  should  be  swabbed  with  half 
tincture  of  iodin  and  packed  after  the  wound  has  been  closed  with  inter- 
rupted No.  2  chromic  sutures.  There  is  no  need  of  drainage  under  the 
bladder. 

TECHNIC  IN  NONPEDUNCULATED  SUBMUCOUS  FIBROIDS. — The  indica- 
tions for  myomectomy  in  this  group  of  tumors  are  comparatively  few, 


FIBROIDS  135 

since  experience  has  shown  that  they  are  far  better  treated  by  hys- 
terectomy. As  in  the  previous  case,  a  hysterotomy  is  made  in  the 
anterior  wall  of  the  uterine  cervix  and  the  bladder  elevated  out  of 
harm's  way.  When  sufficient  exposure  has  been  obtained  in  this  man- 
ner, the  prominent  portion  of  the  growth  is  seized  with  a  tenaculum 
and  an  incision  as  long  as  possible  is  made  through  the  mucosa  and  the 
capsule  of  the  fibroid.  The  tumor  is  then  shelled  out  with  the  fingers 
or  the  scissors,  being  drawn  down  gradually  with  forceps  as  it  is  liber- 
ated. The  larger  tumors  are  best  removed  after  morcellation.  Yet,  as 
emphasized  before,  this  class  of  tumor  is  often  infected,  and  it  is  not 
wise  to  leave  the  uterus,  since  the  convalescence  at  best  may  be  stormy. 
Hemorrhage  is  likely  to  qccur  and  may  not  respond  to  packing.  The 
treatment  is  not  advised,  save  in  the  very  rarest  cases. 

TECHNIC  IN  INTERSTITIAL  FIBROIDS. — The  removal  of  fibroids  of  this 
class  by  morcellation  is  an  obsolete  procedure,  and,  therefore,  does  not 
merit  description.  It  is  mentioned  merely  to  condemn  it.  If  this  type 
of  operation  appears  necessary,  the  uterine  arteries  should  first  be 
ligated.  In  closing,  care  must  be  taken  so  that  the  peritoneum  which 
has  been  reflected  above  the  abraded  areas  is  sutured  above  the  former 
location  of  the  tumor.  This  type  of  case  is  far  better  treated  by 
radium. 

TECHNIC  IN  SUBPERITONEAL  FIBROIDS. — Subperitoneal  fibroids  may  be 
removed  when  the  vagina  is  capacious  and  the  primary  operation  is  designed 
only  for  the  repair  of  the  pelvic  floor.  There  is  no  centra-indication  to 
removing  growths  of  small  size  which  are  situated  upon  the  anterior  surface 
of  the  uterus,  since  the  incision  required  for  the  myomectomy  may  be  cov- 
ered by  the  bladder.  There  is  considerable  risk  of  adhesions  to  the  small 
bowel  if  the  myomectomy  is  made  upon  the  posterior  surface  of  the  uterus,' 
since  one  cannot  well  judge  as  to  the  hemostasis  when  the  uterus  has  been 
inverted  through  a  colpotomy  incision  into  the  vagina. 

The  cervix  is  steadied  with  tenaculae  and  a  transverse  incision  is  made 
into  the  anterior  vaginal  wall  below  the  insertion  of  the  bladder.  If  the 
growth  is  high,  or  of  appreciable  size,  a  vertical  incision  should  be  made  so 
that  the  bladder  may  be  completely  elevated.  The  separation  is  made  with 
the  dissecting  scissors.  When  the  bladder  is  well  elevated  by  a  broad 
retractor,  the  peritoneum  is  incised,  the  fundus  seized,  and  the  uterus  in- 
verted through  the  incision  into  the  vagina,  and  the  growth  is  removed  as 
described  under  abdominal  myomectomy  in  this  class  of  tumors. 

TECHNIC  IN  CERVICAL  FIBROIDS. — Occasionally  cervical  fibroids  which 
grow  on  the  anterior  or  posterior  surface  of  the  cervix  may  be  removed 
without  difficulty  through  the  vagina.  The  vaginal  route  should  be  selected 
only  when  the  growth  is  of  small  size.  Growths  which  develop  in  the  broad 
ligament  are  better  removed  after  abdominal  incision.  If  the  vagina  is  not 
capacious,  it  may  be  dilated  or  enlarged  by  means  of  paravaginal  incision, 
after  which  an  anterior  or  posterior  colpotomy  is  made  and  the  removal 


136  PELVIC  NEOPLASMS 

completed  under  the  eye,  by  the  same  technic  described  under  abdominal 
myomectomy.  In  case  there  is  persistent  oozing,  it  may  be  necessary  to 
ligate  the  uterine  vessels.  The  vaginal  route  is  not,  at  the  present  time, 
regarded  as  the  method  of  choice  except  for  small  tumors.  Complications 
may  be  appreciated  better  after  abdominal  exposure. 

Abdominal  Hysterectomy. — The  body  of  the  uterus  alone  may  be 
removed — supravaginal  hysterectomy;  or  the  entire  uterus  may  be  extir- 
pated— panhysterectomy.  Judging  only  from  theoretical  considerations, 
panhysterectomy  is  preferable  to  the  supravaginal  amputation,  since  it  re- 
moves at  the  same  time  the  chance  that  cancer  may  develop  subsequently  in 
the  cervix.  If  the  woman  has  borne  children,  or  has  a  hypertrophied  or 
lacerated  cervix,  panhysterectomy  is  the  method  of  choice,  if  there  are 
no  contra-indications.  Practically,  however,  the  more  complete  operation 
adds  somewhat  to  the  mortality  in  dealing  with  the  larger  growths.  The 
operation  may  be  divided  further  according  as  the  adnexa  are  or  are  not 
removed. 

Successive  improvements  in  the  technic  of  hysterectomy  have  made  this 
operation  the  most  satisfactory  method  for  removing  the  larger  tumors. 
Its  chief  objection  is  that  it  entails  a  mutilation  of  the  patient  which  should 
be  avoided  in  young  women  whenever  possible.  The  operation,  therefore, 
should  be  performed  only  in  the  cases  in  which  myomectomy  does  not  seem 
to  be  a  reasonable  procedure.  Hysterectomy,  therefore,  is  usually  restricted 
to  the  larger  interstitial  growths,  to  submucous  fibroids,  in  intraliga- 
mentous  growths  which  cannot  be  removed  without  trauma  through 
the  vagina,  and  to  tumors  which  have  undergone  some  evident  degen- 
eration, as  well  as  any  tumor  in  older  women  which  presents  indica- 
tions for  operation. 

HISTORICAL. — The  abdominal  hysterectomy  for  fibroids  has  been 
gradually  perfected  since  Kimball,  in  1853,  performed  the  first  deliber- 
ate hysterectomy  for  an  interstitial  tumor.  Prior  to  that  time,  fibroids 
had  occasionally  been  removed  by  the  more  venturesome  operators 
who  had  opened  the  abdomen  under  the  impression  that  they  were 
dealing  with  ovarian  cysts.  The  earlier  hysterectomies  carried  a  tre- 
mendous mortality,  not  only  from  lack  of  aseptic  technic,  but  also 
because  of  faulty  methods  of  treating  the  uterine  stump  after  the 
removal  of  the  tumor.  As  in  ovariotomy,  the  pedicle  was  treated 
extraperitoneally  and  was  transfixed  in  the  abdominal  wound  because 
the  size  of  the  vessels  in  the  uterine  stump  made  the  surgeons  hesi- 
tate to  drop  it  back  into  the  abdomen.  It  was  usually  fastened  by 
transfixion  in  the  abdominal  wound  with  a  clamp  which  was  tightened 
from  time  to  time  until  the  pedicle  sloughed  away.  Subsequently, 
elastic  ligatures  and  the  serrenoeud  of  Cintrat  replaced  the  clamp.  There 
resulted  from  this  treatment  a  sloughing  mass  which  constantly  exposed 
the  patient  to  dangers  of  sepsis.  Credit  for  the  development  of  the  modern 
method  is  due  to  a  group  of  men,  chief  of  whom  are  Stimson  and.Goffe. 


FIBROIDS  137 

Stimson  urged  that  blood  vessels  should  be  ligated  individually  and  only 
after  they  were  isolated.  Goffe  was  largely  responsible  for  covering  the 
cut  surface  of  the  pedicle  with  peritoneum  after  which  the  stump  was  re- 
placed in  the  abdominal  cavity.  Subsequent  improvements  in  technic  con- 
sist largely  in  the  substitution  of  catgut  for  the  earlier  silk  ligatures,  and 
proper  methods  of  peritonealization.  At  the  present  time,  supravaginal 
hysterectomy  carries  with  it  a  smaller  mortality  than  the  complete  removal, 
in  our  judgment  largely  because  of  faulty  technic.  Yet,  as  we  have  shown, 
the  former  method  is  not  always  the  one  of  choice.  Cervical  stumps  fre- 
quently hypertrophy  after  the  removal  of  the  uterine  body,  cancer  occa- 
sionally develops  in  the  stump,  and  the  troublesome  leukorrheal  discharge 
may  compel  a  later  removal  of  the  cervical  mucosa. 

GENERAL  REMARKS. — The  association  of  sarcoma  and  fibroids  is  so 
common  (4  per  cent  in  all  cases  and  12  per  cent  in  women  of  more  than 
fifty  years  of  age,  according  to  Sutton)  that  the  specimen  should  be  care- 
fully examined  immediately  after  its  removal  if  the  operator  does  not  prac- 
tice total  extirpation  of  the  uterus  as  a  routine  procedure.  Many  advise 
curetting  the  uterus  as  a  preliminary  diagnostic  measure,  yet,  in  our  expe- 
rience, this  is  not  a  satisfactory  practice.  Not  only  is  it  impossible  often 
of  accomplishment  because  of  a  tortuous  uterine  cavity,  but  we  have  fre- 
quently observed  sarcoma  which  did  not  extend  into  the  endometrium. 

Both  of  the  methods  of  hysterectomy  are  usually  done  after  the  vessels 
have  been  clamped  with  hemostats.  There  is  no  doubt  but  that  clamps 
are  very  necessary  in  operations  in  larger  tumors,  yet  a  review  of  a  large 
series  of  cases  will  suggest  to  a  critical  student  that  the  method  may  be 
responsible  for  many  of  the  emboli  which  cause  a  seemingly  uncontrollable 
mortality.  It  does  not  seem  a  reasonable  procedure  to  clamp  vessels  and 
ligate  them  later  in  an  area  in  which  thrombi  are  already  developing.  Clamps 
are  always  in  the  way  in  abdominal  exposure  and  the  trauma  that  is  inci- 
dental to  their  handling  may  quite  likely  favor  extensive  thrombi  and  the 
subsequent  detachment  of  emboli. 

The  method  of  hysterectomy  will  be  described  under  the  headings  of 
supravaginal  hysterectomy  in  uncomplicated  cases,  panhysterectomy  in  un- 
complicated cases,  with  or  without  the  removal  of  the  ovaries  in  each  group, 
as  well  as  the  same  methods  in  complicated  cases. 

TECHNIC  FOR  SUPRAVAGINAL  HYSTERECTOMY  IN  UNCOMPLICATED 
CASES. — The  technic  of  this  operation  varies  slightly  according  as  the  ad- 
nexa  are  removed  or  allowed  to  remain.  The  subject  of  conservatism  in  the 
removal  of  ovaries  has  not  yet  been  settled.  There  is  no  doubt  but  that  the 
removal  of  ovaries  causes  ablation  symptoms  which  occasionally  are  most 
distressing.  Some,  as  Polak,  state  that  they  are  more  frequent  in  women  in 
the  premenopausal  era,  yet  this  does  not  accord  with  our  experiences  as  com- 
piled by  Maxwell.  Ordinarily,  ovaries  should  be  allowed  to  remain  in  young 
women  when  there  is  no  indication  of  disease;  yet  even  with  this  qualifica- 


138  PELVIC  NEOPLASMS 

tion,  we  frequently  find  ovaries  which,  appearing  normal  at  operation,  subse- 
quently develop  into  cysts  which  gradually  give  symptoms. 

Preliminary  Preparation. — The  surgeon  should  see  to  it  that  the  patient 
comes  to  operation  after  a  thoroughly  good  night's  sleep.  It  is  useless 
to  purge  patients  preliminary  to  operation.  It  is  most  distressing  to 
learn  that  a  case  has  been  kept  awake  by  griping  from  a  cathartic. 
We  have  not  purged  patients  preliminary  to  operation  for  more  than 
ten  years.  Bromids  may  be  given  the  night  before  operation  to  induce 
sleep.  A  soap  suds  enema  is  given  a  few  hours  before  operation.  The 
night  before  operation,  the  abdomen  is  washed  with  soap  and  water, 
70  per  cent  alcohol,  and  ether  after  the  pubic  area  has  been  shaved.  A 
dry  dressing  is  placed  on  the  abdomen  and  allowed  to  remain  until  the 
patient  is  anesthetized.  A  hypodermic  of  morphin  1/6  grain  and  atropin 
Yiso  grain  is  given  a  half  hour  before  the  anesthesia.  The  patient  is  anes- 
thetized with  gas  and  oxygen  which  is  then  changed  to  ether.  The 
vagina  is  now  washed  out  with  soap,  water,  ^  per  cent  lysol  solution 
and  70  per  cent  alcohol.  If  there  is  no  vaginal  work  to  be  done,  the 
vagina  is  packed  with  a  long  strip  of  gauze,  after  the  patient  has  been 
catheterized.  The  gauze  keeps  the  vaginal  walls  apart  so  that  they 
cannot  be  contaminated  by  the  cervical  secretion,  elevates  the  neck  of 
the  vagina,  and  gives  a  landmark  which  may  be  easily  recognized  in 
case,  after  the  abdomen  is  opened,  there  may  be  found  indications  for 
drainage.  Formerly,  we  prepared  the  vagina  before  anesthesia.  This 
is  a  better  procedure  in  the  absence  of  a  trained  anesthetist.  As  a 
rule,  however,  it  terrifies  the  patient  and  makes  the  anesthesia  more 
difficult.  The  patient  is  now  placed  flat  upon  the  table  and  the  entire 
surface  of  the  abdomen,  the  top  of  the  pubic  area,  and  the  upper  thighs 
are  washed  with  ether,  70  per  cent  alcohol,  and  one-half  tincture  of 
iodin.  The  skin  is  allowed  to  dry  and  the  field  is  made  sterile  for 
operation  by  draping  sterile  sheets  and  towels  over  all  save  the  place 
selected  for  incision.  The  abdomen  should  never  be  cleaned  with  soap 
and  water  on  the  day  of  operation  if  iodin  sterilization  is  used. 

Opening  the  Abdomen. — The  iodin  is  now  removed  with  70  per 
cent  alcohorfrom  the  area  selected  for  the  incision.  This  is  done  so 
that  no  iodin  may  be  carried  into  the  abdomen  on  the  gloved  hands 
of  the  surgeons,  or  on  the  pack  pads  or  instruments  used  during  opera- 
tion. Experience  has  shown  that  iodin  is  responsible  for  many  intra- 
abdominal  adhesions.  An  incision  is  made  from  the  pubic  hairline  to 
the  navel  which,  in  the  majority  of  cases,  will  suffice  for  the  delivery 
of  the  tumor.  Occasionally  it  is  necessary  to  make  it  somewhat  higher 
and  above  the  umbilicus.  It  is  better  to  excise  the  umbilicus  in  such 
cases.  The  incision  is  made  in  the  midline  and  is  carried  through  the 
linea  alba.  The  recti  muscles  are  separated  from  their  sheaths  in  the 
midline.  The  incision  should  be  carried  well  down  toward  the 
symphysis  to  allow  the  greatest  possible  exposure.  The  last  inch  in 


FIBROIDS  139 

the  lower  angle  of  the  wound  permits  a  better  exposure  of  the  pelvis 
than  twice  that  length  at  the  upper  end  of  the  incision  in  the  region 
of  the  navel.  The  peritoneum  in  the  upper  angle  of  the  wound  is 
picked  up  carefully  and  incised  between  two  forceps  only  after  the 
greatest  care  has  been  observed  that  the  intestine  is  not  included  in  the  bite 
of  the  forceps.  There  is  always  a  chance  that  the  bladder  is  carried 
up  into  the  abdomen  by  the  fibroid,  where  it  could  be  readily  incised.  The 
peritoneal  incision  is  best  made  in  the  very  upper  angle  of  the  wound.  All 
free  sponges  should  be  discarded  before  the  peritoneum  is  incised,  and  only 
sponges  mounted  on  holders  should  be  used  while  the  peritoneum  is  open. 
The  margins  of  the  incision  are  now  separated  with  mechanical  retractors. 
The  upper  abdomen  is  thoroughly  explored  and  the  condition  of  the  kid- 
neys, gall-bladder,  stomach,  pancreas,  spleen,  large  and  small  intestine  is 
noted  and  recorded  as  a  routine  procedure.  The  intestines  are  now  packed 
off  with  a  large  rubber  dam  and  the  pelvis  is  carefully  explored.  The  in- 
testines may  be  replaced  most  easily  if  one  starts  on  the  right  side  of  the 
abdomen,  and  first  packs  off  the  head  of  the  cecum,  and  then  works  to  the 
left,  placing  the  pack  in  such  a  fashion  that  the  intestines  will  not  come 
into  view  during  the  operation.  This  method  also  permits  an  early  in- 
spection of  the  appendix  which,  if  diseased,  may  be  bound  down  with 
adhesions  to  the  tubes  or  tumor.  The  larger  tumors  had  better  be  delivered 
before  the  retractors  are  placed  in  position  or  the  intestines  are  packed  off. 
Occasionally  these  steps  of  the  operation  are  best  not  performed  until  after 
the  tumor  has  been  removed. 

Delivery  of  the  Tumor. — The  tumor  is  ordinarily  delivered  readily  with 
the  hand,  although  a  heavy  tenaculum  or  corkscrew  is  frequently  an  aid  dur- 
ing the  procedure.  Tumors  limited  to  the  body  of  the  uterus  can  be  lifted 
out  readily  through  the  wound,  as  the  unchanged  lower  segment  of  the 
uterus  forms  a  natural  pedicle  for  the  tumor.  When  there  are  multiple 
growths,  a  succession  of  deliveries  may  be  necessary  before  the  mass  can  be 
brought  outside  the  incision.  Too  great  traction  should  not  be  made  for  fear 
of  injuring  blood  vessels  and  exciting  thrombosis.  Sometimes  the  upper 
part  of  the  broad  ligament  must  be  divided  before  the  tumor  can  be  delivered. 
Adhesions  may  complicate  the  delivery ;  they  rarely  give  trouble,  since  they 
are  usually  limited  to  the  appendages.  Slight,  or  nonvascular,  adhesions  not 
attached  to  the  bowel  or  other  structures  which  may  be  injured  easily  should 
be  broken  up  with  the  fingers.  Otherwise,  they  must  be  treated  as  their 
special  characters  demand.  The  surgeon  should  take  care  in  freeing  the 
bowel  from  the  tumor  that  the  line  of  incision  should  be  made  so  that  there 
is  no  chance  of  injury  to  the  bowel,  and  that  there  is  a  -flap  of  peritoneum 
left  sufficient  to  cover  properly  any  abraded  surface  on  the  peritoneal  aspect 
of  that  viscus.  It  is  far  better  to  leave  a  part  of  the  uterus  attached  to  the 
bowel  after  the  adhesions  have  been  severed  than  to  break  through  into  the 
intestines,  contaminate  the  field  of  operation,  and  create  an  injury  which 
would  demand  intestinal  resection. 


140  PELVIC  NEOPLASMS 

TECHNIC  FOR  SUPRAVAGINAL  HYSTERECTOMY  WITH  REMOVAL  OF 
THE  ADNEXA. — This  operation  is  indicated  in  women  in  the  menopausal  age, 
irrespective  of  the  condition  of  the  tubes  and  ovaries.  Such  a  procedure 
removes  all  chance  of  the  development  of  malignant  disease  in  the  ovaries 
at  a  later  period.  It  should  be  performed  on  all  women  irrespective  of 
their  age  who  present  infection  of  the  tubes  and  ovaries.  The  removal  of 
the  uterus  interferes  so  completely  with  the  circulation  of  the  ovaries  that 
no  ovary  which  is  not  absolutely  normal  should  be  allowed  to  remain.  If 
it  is  necessary  to  remove  the  tube,  the  ovary  should  be  taken  with  it.  It  is 
far  better  to  transplant  small  sections  of  the  ovary  into  the  rectus  muscle 
than  to  leave  any  but  a  normal  organ  in  the  peritoneal  cavity.  Even  with 
these  limitations,  a  considerable  number  of  ovaries  will  subsequently  develop 
cyst  formation. 

The  tumor  is  seized  with  a  heavy  tenaculum,  placed  on  the  side  of  the 
uterus,  which  is  to  be  separated  first.  The  infundibulopelvic  ligament  is 
elevated  to  expose  the  ovarian  vessels  which  are  ligated  with  catgut.  A 
pedicle  needle  should  be  passed  through  the  thin,  clear  space  in  the  liga- 
ments immediately  below  the  vessel.  One  should  take  care  that  the  ureters 
are  not  included  in  their  ligatures.  It  is  best  to  place  a  second  suture  distal 
to  the  first,  and  to  tie  each  in  three  knots  so  that  there  is  no  chance  of 
hemorrhage.  The  suture  should  not  be  placed  too  high  up  on  the  vessels, 
since  they  retract  after  division.  The  round  ligament  is  next  ligated  close 
to  the  uterus,  so  that  its  major  portion,  together  with  the  adjacent  perito- 
neum, may  be  left  as  a  flap  to  peritonealize  the  raw  areas  which  are  made 
in  removing  the  tumor.  The  same  procedure  is  now  repeated  on  the  oppo- 
site side,  and  two  of  the  four  cardinal  vessels  are  thus  cut  off  from  the 
uterine  circulation.  The  uterine  end  of  the  infundibulopelvic  ligament 
mesial  to  the  ligation,  and  the  round  ligament  in  the  same  relative  position, 
are  cut  through,  thus  opening  the  top  of  the  broad  ligament  and  exposing 
the  anastomosing  utero-ovarian  vessel.  The  reflux  bleeding  is  controlled 
with  clamps. 

Separation  of  the  Bladder  and  Ligation  of  the  Uterine  Vessels. — The 
uterus  is  now  drawn  upward  and  backward  by  the  tenacula,  an  incision  is 
made,  connecting  the  opening  made  by  severing  the  round  ligaments  at  least 
half  an  inch  above  the  vesico-uterine  reflection  of  the  peritoneum.  The 
fixed  portion  of  the  bladder  in  the  midline  of  the  anterior  surface  of  the 
uterus  is  cut  through  with  scissors ;  then  the  bladder  is  separated  from  the 
uterus  with  dissecting  scissors.  This  creates  less  trauma  than  by  stripping 
the  tissues  down  with  a  sponge.  The  cut  edge  of  the  broad  ligament  is 
elevated  and  an  incision  is  made  between  two  clamps  down  to  the  uterine 
vessels.  The  uterus  is  now  brought  forward  so  as  to  exert  traction  on  the 
posterior  peritoneal  covering  of  the  broad  ligament  in  the  region  of  the 
uterine  vessels.  This  surface  is  now  freed  with  dissecting  scissors  and  cut 
through,  when  the  uterine  vessels  lie  exposed.  After  the  bladder  is  pushed 
down,  the  uterine  vessels  are  exposed  and  ligated  with  a  pedicle  or  ligature 


FIBROIDS  141 

mounted  upon  a  needle.  The  same  procedure  is  carried  out  on  the  oilier 
side.  It  is  quite  useless  to  tie  off  the  blood  vessels  in  the  broad  ligament 
as  you  proceed  down  to  the  uterine  vessels,  since  there  will  be  no  bleeding 
of  importance  after  the  uterine  vessels  are  ligated  in  this  manner.  If 
the  broad  ligament  is  pushed  away  from  the  uterus  or  tumor,  and  the 
suture  is  placed  close  to  the  cervix  or,  in  case  of  doubt,  even  through  its 
tissues,  there  is  no  risk  of  injuring  the  ureters. 

Incision  of  the  Cervix  and  Closure  of  the  Stump. — The  tumor  and  the 
uterus  are  elevated,  while  the  level  of  amputation  is  determined.  This 
site  is  seized  with  a  tenaculum  and  steadied  while  the  tumor  is  removed  by 
cutting  through,  well  above  the  level  of  the  internal  os.  The  amputation 
is  made  by  a  wedge-shaped  incision,  to  leave  anterior  and  posterior  flaps  to 
facilitate  a  broad,  firm  closure.  It  is  not  necessary  to  treat  the  cervix  with 
antiseptics  or  a  cautery  in  order  to  sterilize  it.  Such  treatment  is  more 
likely  to  cause  complications.  The  cervix  is  now  closed  by  uniting  the  flaps 
accurately  with  interrupted  or  continuous  chromic  catgut  sutures.  The 
sutures  should  not  pierce  the  cervical  canal. 

Covering  the  Abraded  Areas. — Any  small  bleeding  points  may  be  in- 
cluded with  a  suture  uniting  the  vessel  to  the  cervical  wall.  The  round 
ligaments  are  brought  down  and  stitched  to  the  posterior  margin  of  the 
cervical  stump  with  No.  2  chromic  catgut  sutures.  The  free  edge  of  the 
bladder  flap  of  peritoneum  is  brought  back  and  stitched  to  the  posterior 
surface  of  the  cervix  to  cover  over  the  raw  edges.  The  stumps  of  the 
ovarian  vessels  and  cut  edges  of  the  broad  ligament  are  now  closed  in  the 
following  manner:  with  a  long  suture  of  No.  oo  plain  catgut  mounted  on 
a  fine  needle,  the  stump  of  the  right  ovarian  vessel  is  inverted  just  as  the 
stump  of  an  appendix.  The  knot  should  be  buried  and  the  anterior  and 
posterior  flaps  of  the  broad  ligament  are  united  so  as  to  leave  exposed 
no  raw  areas  and  the  minimum  of  suture  material.  The  suture  is  con- 
tinued across  the  midline  of  the  pelvis,  tacking  back  the  bladder  flap  of  the 
peritoneum  to  the  cervix  and  proceeding  up  along  the  left  broad  ligament, 
to  finally  invert  the  stump  of  the  left  ovarian  vessel  and  leave  only  a 
single  knot  which  will  be  covered  by  the  sigmoid  colon.  Such  a  procedure 
will  give  an  even  peritoneal  closure,  free  from  raw  surfaces  or  exposed 
knots  which  invite  adhesions.  In  case  there  have  been  inflam- 
matory adhesions,  the  peritoneal  surfaces  should  be  united  so  that  all  raw 
edges  will  be  extraperitoneal.  In  case  this  cannot  be  done,  the  sigmoid 
may  be  utilized  to  cut  off  the  pelvis  from  the  abdomen  so  that  the  small 
intestines  will  not  prolapse  into  the  pelvis  and  become  adherent.  This 
method  is  illustrated  in  Fig.  49,  q.v.  All  free  blood  and  clots  should  be 
removed  by  the  gloved  hand  of  the  operator.  Unnecessary  sponging  adds 
greatly  to  the  peritoneal  trauma  and  favors  adhesions.  All  packs  are  re- 
moved and  counted  by  an  assistant  who  makes  certain  that  their  number 
tallies  with  that  on  hand  at  the  beginning  of  the  operation.  The  peritoneal 


1 42  PELVIC  NEOPLASMS 

cavity  should  not  be  closed  until  the  count  agrees.  No  solution  whatsoever 
should  be  left  in  the  abdominal  cavity. 

Closure'  of  the  Abdominal  Incision. — The  peritoneum  is  closed  by  a 
continuous  plain  No.  2  catgut  suture,  taking  care  that  the  raw  surfaces  are 
extraperitoneal.  As  the  peritoneum  is  closed,  the  omentum  should  be  spread 
between  it  and  the  abdominal  wall.  The  anterior  sheath  of  the  rectus 
and  muscle  should  be  splinted  by  two  or  three  sutures  of  silkworm  gut 
passed  through  the  skin,  fat,  fascia  and  muscle,  coming  out  in  reverse  order. 
The  closure  is  completed  by  uniting  the  fascia  and  muscles  with  double 
interrupted  sutures,  taking  the  greatest  care  that  the  upper  and  lower  angles 
of  the  wound  are  firmly  approximated.  The  skin  edges  are  then  approxi- 
mated accurately  with  Michel  clamps,  or  subcuticular  catgut,  or  a  running 
horsehair  suture,  and  the  incision  is  touched  with  iodin.  Small  rubber 
tubes  half  an  inch  in  length  are  threaded  on  the  retaining  sutures  of  silk- 
worm gut  so  that  they  may  not  be  tied  in  a  way  to  damage  the  under- 
lying tissues  by  pressure.  They  should  not  be  tied  over  a  roll  of  gauze, 
since,  if  it  is  necessary  to  inspect  the  wound,  the  sutures  must  be  cut  before 
there  is  firm  healing.  There  are  many  methods  in  use  for  the  dressing 
of  the  wound.  The  great  majority  are  unnecessary,  since  most  excellent 
results  follow  a  simple  dressing  of  sterile  gauze  which  is  held  in  place  by 
strips  of  adhesive. 

TECHNIC  FOR  SUPRAVAGINAL  HYSTERECTOMY  WHEN  THE  ADNEXA 
ARE  NORMAL. — Normal  adnexa  should  not  be  removed  in  young  women. 
The  operation  proceeds  exactly  as  in  the  previous  method,  save  that  the 
incision  is  made  at  the  margin  of  the  uterus  to  leave  as  much  as  possible 
of  the  uterus  behind,  so  that  the  anastomosing  circulation  between  the 
ovarian  and  uterine  vessels  will  be  disturbed  as  little  as  possible  (Fig.  42). 
Clamps  are  placed  to  include  the  ovarian  ligament  and  tube.  The  uterine 
margin  of  the  round  ligament  is  seized  with  clamps  in  the  same  manner.  In- 
cision is  made  between  the  clamps  and  the  bleeding  points  are  immediately 
tied  with  catgut.  The  ovaries  should  not  remain  if  it  is  necessary  to  re- 
move the  tubes,  since  there  is  every  chance  that  the  ovaries  will  become 
diseased  from  impairment  of  the  circulation.  After  ligature  of  the  car- 
dinal vessels,  all  other  bleeding  points  are  picked  up  and  tied  with  the  finest 
catgut  that  seems  practicable.  The  margin  of  the  uterus  which  remains 
attached  to  the  ovarian  ligament  is  sewed  to  the  stump  of  the  cervix  and 
all  raw  edges  are  well  covered  with  peritoneum  in  a  manner  so  that  each 
ovary  and  tube  will  lie  free  and  not  prolapse  in  the  depths  of  the  pelvis 

(Fig-  39)- 

PANHYSTERECTOMY  IN  UNCOMPLICATED  CASES. — The  complete  removal 

of  the  entire  uterus  and  tumor  is  indicated  whenever  it  does  not  appear 
likely  to  add  greatly  to  the  risk  of  the  operation.  It  is  indicated  in  any 
case  in  which  there  is  suspicion  of  malignant  degeneration  or  when  the 
cervix  is  diseased  as  a  sequence  of  laceration.  The  first  stages  of  the  oper- 
ation are  identical  with  those  of  the  supravaginal  hysterectomy  as  far  as 


FIBROIDS  143 

the  division  of  the  cervix.  In  the  complete  operation,  it  is  necessary  to 
separate  the  bladder  below  the  vaginal  insertion  of  the  cervix.  After  the 
uterine  vessels  are  ligated,  the  parametrium  should  be  tied  off  with  another 
transfixed  ligature.  Incision  of  the  lower  portion  of  the  broad  ligament 
greatly  facilitates  the  elevation  of  the  uterus.  The  uterus  and  tumor  are 


FIG.  42. — HYSTERECTOMY  CONSERVING  THE  TUBES  AND  OVARIES.     Opening  the  broad  liga- 
ment.    The  utero-ovarian  anastomosis  is  preserved  in  the  broad  ligament. 

now  pulled  strongly  forward  and  an  incision  is  made  on  the  posterior  sur- 
face of  the  uterus  just  above  the  insertion  of  the  uterosacral  ligament 
(Fig.  44).  By  elevating  the  uterus,  the  organ  may  be  literally  cored  from 
the  parametrium.  When  the  organ  is  liberated,  save  for  the  vaginal  attach- 
ment, the  vagina  is  opened  either  on  the  anterior  or  posterior  surface  at 
the  cervical  margin.  The  upper  vaginal  edge  is  seized  with  mouse-toothed- 
hemostats  and  the  incision  is  continued  around  the  upper  vagina  (Fig.  45). 


144  PELVIC  NEOPLASMS 

The  hemostats  serve  as  retractors  and  facilitate  closure.  There  are  a  few 
vessels  in  the  parametrium  which  will  bleed  and  require  ligation.  They 
may  be  clamped  and  tied,  taking  the  greatest  care  not  to  injure  nor  tie  off 
the  ureter  which  is  a  very  short  distance  from  the  incision.  The  entire 


FIG.  43. — SUPRA  VAGINAL  HYSTERECTOMY.     Incision  of  the  cervix. 

pelvis  should  be  walled  off  by  gauze  packs  before  incision  of  the  vagina. 
The  vagina  is  now  closed  with  interrupted  chromic  catgut  sutures.  Three 
sutures  should  be  left  as  landmarks  until  the  pelvic  floor  is  built  up,  those  on 
the  two  sides  and  the  one  in  the  middle.  All  who  have  been  concerned  in 
the  operation  now  change  their  gloves,  which  have  been  contaminated 
theoretically  by  contact  with  the  vagina.  All  instruments  and  sutures  which 


FIBROIDS 


have  been  used  are  now  discarded.  The  wound  is  freshly  draped  and  the 
packs  are  removed  so  that  closure  may  be  made  under  direct  inspection. 
The  rubber  dam  holding  back  the  intestines  is  not  disturbed.  The  para- 
metrial  tissues  are  united  to  the  edge  of  the  vagina  and  the  fascia  of  the 
bladder.  The  round  ligaments  are  tied  to  the  posterior  vagina  in  the  mid- 


Tuba 


FIG.  44. — PANHYSTERECTOMY.     The  broad  ligaments  have  been  opened,  and  the  posterior 
peritoneal  cuff  is  being  made. 

line  and  near  the  level  of  the  incision.     Peritonealization  is  made  in  the 
same  manner  described  in  the  previous  section  (Fig.  48). 

ATYPICAL  OPERATION  IN  COMPLICATED  CASES. — Serious  complications 
from  pelvic  infection  present  so  frequently  that  many  operative  technics 
have  been  developed  to  meet  and  overcome  them.  They  all  have  the  same 
underlying  principle  of  reducing  a  complicated  state  to  a  simple  one  before 


146 


PELVIC  NEOPLASMS 


attempting  the  removal  of  the  tumor.  Nearly  all  these  methods  attack  the 
adherent  masses  from  below  after  the  removal  of  the  tumor.  In  our  judg- 
ment, the  average  operator  will  do  better  first  to  free  the  adherent  adnexa 
and  to  separate  such  adhesions  as  bind  down  the  tumor,  and  then  proceed  in 


urt/t. 


Li  v.  rot. 

if 


ffectum 


FIG.  45. — ABDOMINAL  PANHYSTERECTOMY  SHOWING  DENUDED  AREAS  AFTER  THE  REMOVAL 
OF  UTERUS,  TUBES  AND  OVARIES  (Doederlein-Kronig). 

a  typical  manner.  If  the  adherent  masses  are  in  the  way  and  landmarks 
are  not  visible,  the  tube  and  ovary  are  tied  off  at  the  uterine  margin  and  left 
in  place  until  after  the  removal  of  the  tumor.  The  complications  will  then 
appear  more  simple  and  easier  to  treat.  When  the  adhesions  of  bowel 
are  so  dense  that  this  does  not  seem  a  rational  method,  exposure  may 


FIBROIDS  147 

be  obtained  by  opening  the  tops  of  the  broad  ligaments  and  obtaining  a  more 
safe  line  of  cleavage.  If  the  adhesions  cannot  be  freed  from  above  without 
considerable  chance  of  serious  injury  to  the  intestines,  it  is  better  to  ligate 
the  ovarian  vessels,  open  up  the  broad  ligament  and  proceed  from  below 
and  in  front.  Occasionally,  the  capsule  of  the  tumor  may  be  split  and  the 
tumor  extirpated,  leaving  the  capsule  on  the  intestinal  wall  for  the  time 
being,  until  the  pelvic  mass  has  been  removed,  when  a  smooth  closure  can 
be  made.  Cases  complicated  with  abscesses  in  the  cul-de-sac  should  not  be 
operated  until  some  time  after  the  pus  sacs  have  been  drained  through  the 
vagina.  The  risk  of  infection  from  the  dissemination  of  pus  throughout 


FIG.  46. — CLOSURE  OF  VAGINA  IN  PANHYSTERECTOMY. 

the  wide  cellular  areas  created  by  the  removal  of  the  tumor  would  consti- 
tute a  serious  menace  to  the  safety  of  the  individual. 

The  most  difficult  cases  are  usually  those  in  which  the  uterus  and  tumor 
are  firmly  fixed  in  the  pelvis  by  a  pelvic  inflammatory  condition  sufficiently 
marked  as  to  obscure  the  important  landmarks.  The  bladder  is  occasionally 
forced  into  a  position  which  further  obscures  the  relationships.  The  danger 
from  trauma  while  blindly  attempting  to  break  up  adhesions  is  very  great, 
since  it  may  excite  serious  hemorrhage  and  scatter  infection  throughout  the 
entire  wound.  These  cases  may  be  more  easily  removed  after  Kelly's 
method  of  bisection  of  the  tumor,  although  there  is  no  doubt  that  there  is 
considerable  danger  of  infection  when  operating  by  this  method. 


148 


PELVIC   NEOPLASMS 


When  there  is  a  large  intraligamentons  growth  on  one  side  complicated 
by  adhesions,  the  methods  of  Pryor  and  Kelly  will  be  found  advantageous. 
They  are  identical  in  principle,  although  Kelly's  is  a  supravaginal  hysterec- 
tomy while  Pryor's  is  essentially  a  panhysterectomy. 

KELLY'S  LEFT  TO  RIGHT  OR  RIGHT  TO  LEFT  SUPRAVAGINAL  HYSTEREC- 
TOMY.— This  consists  in  a  continuous  incision  down  through  one  broad 
ligament  across  the  cervix  and  up  through  the  other  broad  ligament,  in  con- 
trast with  the  classic  method  in  which  incisions  are  made  from  above  down 


FIG.  47. — PANHYSTERECTOMY.  The  parametria  has  been  built  up  in  angles  of  vagina 
incision.  The  round  ligaments  are  now  sutured  to  the  vaginal  vault.  The  adnexa  are 
fastened  near  the  midline. 

on  each  side  of  the  broad  ligament  and  the  vessels  are  ligated  before  the 
cervix  is  amputated  (Fig.  50).  It  is  suited  especially  to  the  removal  of 
intraligamentous  growths.  The  start  should  be  made  on  the  side  which 
is  more  free  from  complication.  The  broad  ligament  on  the  one  side  is 
ligated,  as  in  the  more  usual  operations,  and  the  bladder  is  separated  and 
pushed  down  to  expose  the  supravaginal  cervix.  The  edge  of  the  uterus 
and  tumor  is  now  separated  from  its  broad  ligament,  cutting  between  clamps 
until  the  uterine  artery  is  reached.  This  is  clamped  or,  in  our  judgment, 
better  ligated  as  a  primary  procedure.  The  uterine  vessels  are  now  divided. 
A  heavy  tenaculum  is  placed  on  the  side  of  the  uterus  which  has  just  been 


FIBROIDS 


149 


freed,  immediately  above  the  level  chosen  for  amputation  while  traction  is 
made  by  means  of  the  tenaculum,  and  the  cervix  is  cut  across,  coring  it  to 
facilitate  subsequent  closure.  When  the  last  fibers  of  the  cervix  are  severed, 
the  other  uterine  artery  is  exposed  and  caught  with  forceps  half  an  inch  above 
the  level  of  the  cervical  level  and  consequently  above  the  immediate  neigh- 
borhood of  the  ureters.  By  pulling  the  uterus  strongly  over  to  the  side 
which  was  first  freed,  the  intraligamentous  nodule  may  be  shelled  out  from 


FIG.  48. — PERITONEALIZATION  FOLLOWING  SUPRA  VAGINAL  OR  PANHYSTERECTOMY. 

the  broad  ligament  without  risk  of  injuring  the  ureter.  By  continued  trac- 
tion, the  round  ligament  and  ovarian  vessels  are  now  exposed  from  below, 
and  clamped,  or  ligated  and  cut.  The  incision  is  now  closed  in  the  manner 
already  described. 

PRYOR'S  METHOD. — Pryor's  method  of  panhysterectomy  for  tumors  of 
one  side  is  as  follows:  the  ovarian  vessels  and  the  round  ligaments  are 
ligated  on  both  sides.  The  bladder  is  separated  and  pushed  down  until  the 
vaginal  cervix  can  be  palpated  through  the  anterior  vaginal  wall.  The  broad 


ISO  PELVIC  NEOPLASMS 

ligament  is  incised  on  the  free  side  from  above  down  until  the  uterine  ves- 
sels are  exposed  and  ligated.  The  uterus  and  tumor  are  then  held  firmly 
back  and  up  and  the  vagina  is  opened  in  front.  The  incision  is  first  carried 
around  to  the  side  in  which  the  vessels  have  been  ligated.  The  uterus  is  then 
pulled  strongly  over  to  the  side  presenting  the  complications;  the  lateral 
lower  margin  of  the  cervix  which  has  just  been  freed  from  the  broad  liga- 


FIG.  49. — PERITONEALIZATION  BY  THE  USE  OF  THE  SIGMOID  COLON  TO  COVER  RAW  AREAS  IN 
THE  PELVIS  AFTER  HYSTERECTOMY. 


ment  is  seized  with  tenacula  and  elevated,  thus  putting  the  intact  portion 
of  the  vagina  on  the  stretch.  This  is  cut  through,  freeing  the  cervix  and 
exposing  the  uterine  artery  which  is  ligated  and  cut  very  close  to  the  cervix 
under  direct  sight.  The  cut  edges  of  the  vagina  are  clamped  together  to 
limit  the  contamination  and  covered  with  gauze  packs.  The  cervix  is  also 
covered  with  a  small  sponge  to  prevent  extrusion  of  its  contents.  The 
intraligamentous  growth  can  then  be  shelled  out  of  the  broad  ligament 


FIBROIDS  151 

without  fear  of  injuring  the  ureter.  The  incision  is  then  carried  upward  as 
in  the  previous  manner.  Although  the  six  cardinal  vessels  have  been  ligated, 
other  small  vessels  may  bleed,  particularly  in  the  paravaginal  tissues.  These 
will  require  separate  ligation.  After  hemostasis  is  complete,  the  vaginal 
wound  is  closed  in  the  same  manner  as  described  under  typical  panhysterec- 
tomy.  This  method,  while  comparatively  easy,  carries  considerable  risk  of 
infection,  as  does  any  procedure  which  opens  the  vagina  before  the  opera- 
tion is  sufficiently  developed  so  that  it  may  be  closed  immediately. 


v.ves. 


.ouni  lig. 


FIG.  50. — KELLY'S  LEFT  TO  RIGHT  METHOD  OF  HYSTERECTOMY  (Kelly). 

When  intraligamentous  growths  are  present  in  both  sides,  Pryor  advo- 
cated a  method  which  first  removed  the  nodules  and  allowed  the  ureters  to 
return  to  their  normal  position  before  the  uterus  was  removed.  The 
ovarian  vessels  and  round  ligaments  are  ligated  and  the  bladder  is  detached 
from  the  cervix.  The  anterior  wall  of  the  uterus  is  elevated  with  tenacula 
and  is  split  from  the  fundus  down,  through  the  cervix  into  the  vagina.  A 
lateral  incision  is  then  made,  through  the  endometrium  through  the  uterus  to 
the  base  of  the  tumor,  which  is  seized  and  fixed  with  a  corkscrew  and 
enucleated.  The  posterior  wall  of  the  uterus  is  then  divided  and  that  half 
of  the  uterus  which  was  first  cut  laterally  is  removed.  The  procedure  is 
then  repeated  on  the  other  side.  This  method  is  not  as  reasonable  as  the 
Kelly  bisection  method. 


152 


PELVIC  NEOPLASMS 


KELLY'S  BISECTION  METHOD. — When  the  fibroids  are  incarcerated 
within  the  pelvis  and  held  down  by  a  pelvic  inflammatory  mass,  Kelly  found 
that  they  could  be  removed  very  readily  after  the  bisection  method.  There 
is,  however,  considerable  mortality  attached  to  this  procedure,  since  one  may 
open  very  frequently  into  an  accumulation  of  pus  within  the  uterine  cavity. 
The  method  is  based  upon  exposure  secured  by  the  uterine  bisection,  thus 
permitting  the  growths  to  be  attacked  from  below  the  level  of  their  dense 
adhesions.  The  bladder  is  freed  from  the  cervix  in  the  usual  manner. 
Usually,  the  ovarian  vessels  cannot  be  exposed  for  ligation  in  the  cases  in 
which  this  procedure  is  indicated.  The  fundus  is  grasped  and  cut  between 
two  large  tenacula,  directly  into  the  uterine  cavity.  A  large  hemostat  placed 
in  the  cavity  will  maintain  the  landmarks.  While  the  incision  is  made,  the 
uterus  is  elevated,  and  the  lower  portions  are  raised  by  seizing  them  with 
other  tenacula  as  the  incision  continues.  When  the  cervix  is  reached,  it  is 
amputated  in  successive  halves,  and  each  half  is  removed  in  a  manner 
identical  with  that  described  in  the  left  to  right  or  right  to  left  removal.  By 
this  means,  the  enucleation  of  the  inflammatory  masses  is  simple,  since  the 
large  vessels  are  easily  reached. 

There  are  a  number  of  other  atypical  procedures  which  can  be  used  if 
the  conditions  appear  to  warrant  them.  The  best  known  of  these  is  the 
Doyen  panhystcrcctomy  which  is  so  clearly  shown  by  Fig.  43,  that  further 
description  is  not  merited.  While  the  illustration  depicts  the  use  of  this 
method  in  a  noncomplicated  case,  it  is  of  greatest  value  when  the  tumor 
is  complicated  by  inflammatory  conditions.  In  such  cases,  the  bladder 
should  be  stripped  down  and  the  incision  made  from  the  front,  when  the 
inflammatory  masses  may  be  shelled  out  from  the  tissues  after  the  vessels 
have  been  ligated,  as  described  in  Kelly's  left  to  right  and  right  to  left 
method. 

Modifications  of  this  method  have  been  described  by  a  number  of  men. 
Since  they  are  so  manifestly  derived  from  the  Doyen  method  and  differ  not 
at  all  in  principle,  it  is  not  worth  while  to  attach  a  name  to  the  procedure. 
After  the  uterus  has  been  elevated  into  the  abdominal  incision,  the  posterior 
portion  of  the  uterus  is  seized  with  a  tenaculum  and  the  uterus  is  amputated 
at  the  level  of  the  internal  os,  taking  care  not  to  cut  into  the  broad  ligament 
and  incise  the  uterine  vessels.  While  the  amputated  margin  is  drawn  firmly 
backward  and  upward,  the  broad  ligaments  are  then  incised  at  their  edge 
and  the  vessels  encountered  are  clamped  as  they  are  met  with. 

TECHNIC  IN  FIBROIDS  DEVELOPING  FROM  THE  POSTERIOR  CERVICAL 
CORPOREAL  JUNCTION. — These  growths  extend  downward  from  their  point 
of  origin,  burrowing  between  the  rectum  and  the  uterus,  carrying  the 
latter  up  against  and  above  the  symphysis  and  elevating  the  peritoneum  in 
the  Douglas  fold.  These  growths  are  very  difficult  to  remove  without 
injury  to  the  rectum,  since  there  is  no  peritoneum  between  the  tumor  and 
the  bowel.  The  safest  method  of  procedure  is  to  separate  the  tumor  at  its 
point  of  origin,  and  then  remove  the  uterus  by  a  supravaginal  amputation. 


FIG.  51. — DOYEN'S  PANHYSTERECTOMY.     The  vagina  has  been  opened  from  behind  and  the 
cervix  seized,  elevated  and  the  excision  of  the  uterus  begun  (Doederlein-Kronig). 


153 


154 


PELVIC  NEOPLASMS 


The  tumor  may  then  be  seized  on  its  anterior  aspect  and  the  connective 
tissue  capsule  split,  when  the  growth  may  be  enucleated,  leaving  the  capsule 


: 


f  ' 


FIG.  52. — DOYEN'S  PANHYSTERECTOMY  ( Boeder lein-Kronig). 


attached  to  the  anterior  wall  of  the  bowel.     If  hemostasis  cannot  be  made 
complete,  the  pocket  should  be  drained  through  the  vagina  by  a  gauze  wick. 


FIBROIDS  155 


RELATION  BETWEEN  FIBROIDS  AND   PREGNANCY 

Sterility. — There  is  no  doubt  but  that  the  fibroid  statistics  of  the 
literature  show  a  higher  proportion  of  sterile  marriages  than  similar 
cases  without  known  tumors,  yet  it  is  an  open  question  whether  the 
fibroids  are  responsible  for  the  sterility  or  really  result  because  the  man 
or  woman  is  sterile. 

It  is  very  difficult  to  obtain  statistics  as  to  sterility  in  women  in 
general.  In  the  series  of  Sims,  Simpson,  Wells  and  Duncan,  there  was 
sterility  in  from  8  per  cent  to  15  per  cent  of  cases.  Young  and  Williams 
found  sterility  in  10.5  per  cent  of  238  women  who  were  medical  cases 
who  gave  no  symptoms  referable  to  the  pelvis  and  who  were  of  the 
same  average  age  as  their  series  of  fibroid  cases,  that  is,  thirty-eight 
and  four-tenths  years.  Hofmeier  found  sterility  in  447  of  2,795  private 
cases  (17  per  cent)  as  contrasted  with  441  cases  of  sterility  in  5,462 
women  in  the  Polyclinic  (8.1  per  cent).  Goetze  found  sterility  in  7 
per  cent  of  730  gynecologic  cases,  including  those  with  fibroids. 
Grunewaldt  found  sterility  in  21  per  cent  of  900  cases  who  complained 
of  symptoms  referable  to  the  pelvis  and  in  whom  congenital  conditions 
were  deemed  sufficient  to  account  for  the  sterility  in  all  cases.  There 
is  no  doubt  that  the  literature  shows  an  increased  frequency  of  sterility 
in  fibroid  cases.  Olshausen  collected  the  cases  of  West,  Roehrig, 
Beigel,  Schumacher,  Scanzoni,  Michels,  Winckel,  Schorler,  and  Hof- 
meier and  found  that  30  per  cent  of  the  1,730  married  women  who  had 
fibroids  were  sterile.  In  the  same  manner,  we  have  found  that  sterility 
existed  in  31.5  per  cent  of  3,617  similar  cases,  adding  to  the  above 
series  the  cases  of  Schroeder,  Young  and  Williams,  Haultain,  Goetze, 
Kelly  and  Cullen.  Yet  in  our  review,  we  find  that  errors  have 
crept  in  from  the  incorrect  translation  of  some  of  the  earlier  series 
forming  the  basis  of  Olshausen's  calculations.  There  are  also  errors 
due  to  the  variation  in  the  usage  of  common  terms,  since  some  have 
accepted  as  sterile  cases  which  have  been  pregnant  but  which  aborted 
before  reaching  term,  while  others  have  included  these  as  fertile.  Yet, 
after  making  a  maximum  of  deductions,  it  would  appear  that  approx- 
imately 25  per  cent  of  these  3,600  cases  were  sterile. 

Careful  review  convinces  us  that  tubal  and  ovarian  disease  is  often 
responsible  for  the  sterility  observed  in  fibroids.  Kelly  and  Cullen 
found  that  both  tubes  were  bound  down  with  adhesions  in  364  of  their 
934  cases;  one  tube  alone  was  affected  in  59  other  cases.  The  ovaries 
showed  some  deviation  from  the  normal  in  more  than  half  the  entire 
series  (496  of  934  cases).  Young  and  Williams  found  inflammatory 
change  in  the  adnexa  of  35  of  their  163  cases  operated  for  fibroids. 
Whether  the  tumor  is  the  cause  of  these  complications  in  any  marked 
percentage  of  cases  it  is  impossible  to  say.  There  is  no  doubt  that  the 


156  PELVIC  NEOPLASMS 

fibroid  occasionally  may  cause  adhesions  through  friction  and  the 
reaction  attending  the  various  degenerations.  Yet  venereal  infection 
cannot  always  be  excluded;  nor  sterility  due  to  the  husband.  Young 
and  Williams  investigated  the  histories  of  31  married  women  with 
inflammatory  lesions  in  the  appendages.  Ten  of  these  were  sterile, 
while  21  had  borne  children,  percentages  closely  approximating  those 
of  the  fibroid  cases  with  normal  adnexa. 

There  is  no  doubt  that  the  location  of  the  tumor  has  some  influence 
upon  the  sterility.  Schorler,  in  253  cases,  found  sterility  in  9  per  cent 
of  the  cases  with  fibroid  polyps,  16.7  per  cent  of  those  with  cervical 
fibroids,  24.7  per  cent  of  cases  with  interstitial  growths,  38.8  per  cent  of  sub- 
mucous  and  47.8  per  cent  of  subserous  growths.  Young  and  Williams  found 
sterility  in  27  per  cent  of  their  cases  with  interstitial  tumors,  31  per 
cent  in  submucous  cases,  and  42  per  cent  in  the  subserous  (Fig.  44). 
Goetze  arranged  his  cases  in  four  groups,  according  to  the  size  and 
number  of  tumors  and  the  severity  of  symptoms.  The  sterility  given 
for  these  various  groupings  ranged  from  13.6  per  cent  for  the  simple 
tumors  less  than  the  size  of  an  apple,  to  50  per  cent  with  growths  the 
size  of  a  man's  head  or  larger.  Goetze  also  emphasized  that  91  per  cent 
of  his  fibroid  cases  presenting  submucous  growths  had  borne  children, 
and  calls  attention  to  the  rarity  with  which  this  form  of  tumor  is  seen 
in  nullipara. 

Fibroids  are  more  frequent  in  the  fifth  decade  of  life  while  preg- 
nancy is  most  common  in  the  third,  a  difference  of  twenty  years.  In 
attempting  to  draw  conclusions,  we  should  remember  that  there  is 
ample  opportunity  during  this  long  period  for  other  conditions  to 
develop  which  will  cause  sterility.  There  are  many  who  believe  that  in 
the  majority  of  cases  the  sterility  is  the  cause  of  the  fibroid  rather  than 
the  fibroid  the  cause  of  the  sterility.  Nearly  all  authors  unite  in  stating 
that  "one  child,"  or  relative  sterility,  is  commonly  observed  in  fibroid 
cases.  Of  68  cases  reported  by  Pinard,  30  had  not  been  pregnant  for 
more  than  ten  years. 

The  Effect  of  Pregnancy  on  the  Tumor. — The  tumor  increases 
rapidly  in  size  during  pregnancy,  according  to  Caseaux  frequently 
attaining  the  size  of  a  year's  growth  in  three  or  four  months.  Cases 
are  reported  where  a  tumor  the  size  of  a  hen's  egg  grew  to  that  of  a 
four-months  pregnancy  before  the  end  of  gestation.  The  increase  in 
size  is  partly  due  to  actual  growth  resulting  from  the  stimulation  of  the 
muscle  fibers  by  the  increased  vascularity  and  the  influence  of  preg- 
nancy, and  partly  due  to  edema.  The  actual  growth  is  due  to  the  pro- 
liferation and  hyperplasia  of  muscle  cells,  while  the  fibrous  elements  do 
not  share  so  actively  in  the  growth.  Occasionally,  the  growth  attains 
enormous  size  from  edema.  Interstitial  and  submucous  tumors  are  most 
likely  to  be  affected.  Polyps  are  often  reported  which,  having  out- 
grown the  space  available  in  the  uterus,  are  forced  into  the  cervix 


FIBROIDS 


157 


without   inducing  labor.      Bleeding   may   continue   during  pregnancy 
with  submucous  growths.    Nauss  observed  it  19  times  in  his  series. 

As  the  uterus  rises  out  of  the  pelvis,  the  tumors  attached  to  it 
usually  become  displaced  above  the  pelvic  brim.  Even  growths  in  the 
lower  segment  become  drawn  up  during  pregnancy  or  labor,  unless 
they  are  on  the  posterior  surface  of  the  uterus  and  sufficiently  large  to 
be  impacted  in  the  pelvic  cavity.  Cervical  and  intraligamentous 
growths  are  not  usually  displaced,  unless  they  are  driven  down  during 
labor,  sometimes  in  advance  of  the  head,  when  they  may  be  forced  out 


FIG.  53, — PREGNANCY  WITH  MULTIPLE  INTRAMURAL  SUBSEROUS  FIBROIDS. 

of  the  canal  or,  more  frequently,  remain  as  an  obstacle  to  delivery.     As 
the  uterus  enlarges  and  rises  up,  the  fibroids  become  flattened. 

The  majority  of  cases  present  no  symptoms.  When  symptoms  occur, 
they  are  usually  due  to  pressure.  Cases  have  been  recorded  which 
cause  intestinal  obstruction.  Symptoms  occasionally  arise  from  the 
overdistention  of  the  abdomen  and  the  pressure  upon  the  diaphragm 
from  large  tumors  late  in  pregnancy.  Various  degenerations  may 
occur  during  pregnancy.  Virchow  described  cyst  formation  with  and 
without  hemorrhage.  Tarnier  and  Mackenrodt  emphasized  the  fre- 
quency of  necrosis.  Torsion  of  the  pedicle  may  also  occur,  the  twist 
involving  either  the  tumor  proper  and  sometimes  even  the  womb  itself. 


i58  PELVIC  NEOPLASMS 

Piquand  and  Lemeland  have  collected  25  such  cases.  At  a  result  of 
the  torsion,  various  degenerations  occur,  ranging  from  simple  edema 
to  necrosis  and  gangrene  and  subsequent  peritonitis.  Red  degenera- 
tion is  a  common  complication  of  fibroids  and  pregnancy,  and  is  usually 
responsible  for  pain  occurring  in  the  tumor.  It  often  necessitates 
operative  removal. 

Abortion. — Gusserow,  compiling  the  literature  prior  to  1880,  stated 
that  abortion  occurs  in  21  per  cent  of  cases,  but  it  is  not  always  pos- 
sible, from  his  references,  to  determine  whether  they  were  spontaneous 
or  resulted  from  operative  procedures.  Chahbazian,  in  1882,  found 
spontaneous  abortion  in  8.2  per  cent  of  his  cases.  Hofmeier  gives  10 
per  cent.  Pozzi,  however,  in  1909,  stated  that  5  or  6  per  cent  more 
nearly  represented  the  true  proportion  at  the  present  time.  This 
tendency  for  the  spontaneous  termination  of  pregnancy  is  also  evident 
in  the  later  months  when  premature  labor  occurs.  Lefour  states  that 
this  occurred  in  10  per  cent  of  his  227  cases,  and  Chahbazian  in  13.8 
per  cent  of  his  series.  The  irritability  of  the  uterus  which  precipitates 
labor  may  be  explained  by  reflex  contractions  of  the  myometrium, 
because  of  the  presence  of  the  tumor,  or  the  frequent  association  of  an 
unhealthy  mucosa  or  a  chronic  metritis  in  fibroid  cases.  On  the  other 
hand,  a  uterus  may  be  extremely  tolerant  of  both  pregnancy  and 
fibroids,  and  instances  of  twins  and  triplets  born  at  term  are  recorded 
by  Lefour,  Carstens,  and  MacClintock. 

Fetal  Position. — The  position  of  the  child  is  often  changed  because 
of  tumors  which  block  the  pelvis  or  encroach  upon  the  uterine  cavity. 
Breech  and  transverse  positions  are  far  more  common  than  under  nor- 
mal conditions.  Lynch  found  that  vertex  presentations  constituted  but 
59  per  cent  of  304  cases,  breech  presentations  22  per  cent,  and  shoulder 
presentations  18  per  cent. 

Labor. — Fibroids  of  the  body  of  the  uterus  rarely  cause  dystocia  by 
blocking  the  outlet.  Cervical,  intraligamentous  growths  and  pedunculated 
subperitoneal  tumors  which  have  become  impacted  in  the  pelvis  are  far 
more  apt  to  cause  difficulty  (Figs.  45,  46).  More  frequently,  they  cause 
uterine  inertia  by  interfering  with  muscular  contractions.  The  great  major- 
ity of  tumors  situated  in  the  lower  uterine  segment,  as  well  as  the  smaller 
cervical  growths,  may  offer  no  mechanical  obstruction  to  labor,  since 
they  are  drawn  up  above  the  presenting  parts  of  the  child  during  the 
formation  of  the  lower  uterine  segment.  The  cases  which  are  most 
likely  to  give  trouble  are  situated  on  the  posterior  cervical  wall  and 
have  become  impacted  in  the  pelvis.  The  important  consideration, 
therefore,  so  far  as  the  prognosis  for  delivery  is  concerned,  depends  not 
only  on  the  situation  but  also  on  tHe  size  of  the  tumor  and  its  con- 
sistency and  degree  of  motility. 

The  course  of  labor  is  frequently  delayed  due  to  (a)  slow  dilatation  of 
the  cervix  from  weak  uterine  contractions;  (&)  premature  rupture  of  the 


FIBROIDS 


membranes  (75  per  cent  of  all  cases) ;  (c)  faulty  presentations  (breech  and 
transverse). 

There  is  no  doubt  but  that  the  second  stage  may  also  be  prolonged 


FIG.  54. — FIBROID  IN  POSITION  TO  CAUSE  DYSTOCIA. 

because  of  weak  contractions.  The  contractions  are  frequently  very 
painful.  The  placenta  may  be  retained  and  is  often  difficult  to  remove 
manually,  particularly  if  the  passage  is  blocked  by  growths  which  have 
been  displaced  by  the  rearrangement  of  the  musculature.  Hemorrhage 


160  PELVIC  NEOPLASMS 

is  a  more  frequent  complication,  because  faulty  contraction  and  retrac- 
tion prevent  the  enlarged  sinuses  from  thrombosing  normally.  Pla- 
centa praevia  has  been  described  so  frequently  that  a  fibroid  uterus 
must  be  considered  as  a  strong  predisposing  factor. 

Puerperium. — Danger  from  complication  of  fibroids  has  not  been 
removed  with  the  termination  of  labor,  since  many  observations  sug- 
gest that  the  puerperium  may  be  the  most  dangerous  period. 

It  is  true  that  many  tumors  decrease  in  size  during  this  period,  paripassu 
with  the  involution  of  the  uterus,  and  give  rise  to  no  symptoms.  The 
complete  disappearance  of  a  fibroid  after  labor  is  not  proved.  Red 
degeneration  has  already  been  mentioned  and  may  give  rise  to  most 
acute  symptoms  in  the  puerperium.  Infection  and  necrosis  of  fibroids 
is  particularly  apt  to  occur  when  submucous  growths  and  interstitial 
fibroids  are  forced  from  their  former  position  into  the  uterine  cavity. 
We  have  seen  several  cases  where  interstitial  growths  were  expelled 
from  a  uterus  studded  with  fibroids  during  the  puerperium  (Fig.  53). 

Treatment. — It  must  be  remembered  that  pregnancy  associated 
with  fibroids  usually  runs  a  perfectly  normal  course  and  that  obstruc- 
tion to  labor  occurs  rarely,  and  usually  only  when  the  tumor  is  situated 
low  down  and  has  become  impacted  in  the  pelvis;  and  that  the  third 
stage  is  frequently  complicated  by  immediate  or  delayed  postpartum 
hemorrhage.  Complications  in  the  puerperium  are  at  least  as  numer- 
ous as  they  are  in  labor  and  pregnancy,  and  may  be  of  grave  signifi- 
cance. No  absolute  rule  can  be  laid  down  for  treatment,  as  each 
individual  presents  its  own  problems.  In  early  pregnancies,  no  treat- 
ment is  indicated,  if  there  is  neither  bleeding  nor  symptoms  from 
pressure.  Should  pressure  symptoms  or  pain  because  of  degenerations 
develop,  myomectomy  is  the  most  conservative  treatment  in  young 
women,  provided,  of  course,  the  growth  does  not  encroach  upon  the 
mucosa.  If  the  woman  is  near  the  menopause,  hysterectomy  should  be 
done.  If  the  tumor  appears  to  block  engagement  or  obstruct  labor  in 
the  earliest  stages,  the  patient  should  be  delivered  by  a  cesarean  sec- 
tion, after  which  myomectomy  or  hysterectomy  may  be  done.  There 
is  no  doubt,  however,  that  cesarean  section  is  done  on  myriads  of  cases 
with  fibroids  without  proper  indication.  The  degenerative  processes 
which  supervene  during  the  puerperium  may  demand  hysterectomy. 
Hysterectomy  is  indicated  as  soon  as  the  growth  is  known  to  be 
infected. 

A  review  of  the  literature  indicates  clearly  that  the  great  mass  of 
surgeons  attending  fibroid  cases  complicated  by  pregnancy  are  not 
conversant  with  the  ordinary  course  of  events.  This  is  shown  by  a 
study  of  Carsten's  516  collected  cases.  Hysterectomy  was  done  prior  to  fetal 
viability  in  46.4  per  cent  of  cases.  In  other  words,  nearly  one  half  of 
the  cases  of  the  literature  up  to  1909  were  treated  as  fibroids  alone. 
This  treatment  was  inspired,  no  doubt,  by  the  fear  that  the  cases  could 


FIBROIDS 


161 


not  progress  to  term.  On  the  contrary,  Lobenstein,  who  reported  in 
1911  a  series  of  100  cases,  found  that  85  came  to  term,  and  that  an 
absolutely  spontaneous  labor  occurred  in  75  per  cent  of  his  total  series, 


FIG.  55. — INTERIOR  OF  UTERUS  SHOWN  IN  FIG.  54. 

a  percentage  which  was  increased  to  87  per  cent  if  we  include  deliveries 
made  with  low  and  mid  forceps.  Pinard's  series,  1895-1901,  shows 
equal  results.  Intervention  was  necessary  during  pregnancy  in  4  of 


1 62  PELVIC  NEOPLASMS 

his  85  cases;  spontaneous  delivery  ensued  in  54  cases.  Spontaneous 
delivery  ensued  in  64  per  cent  of  Pinard's  series  of  1901-1904,  and  in 
68  per  cent  of  Troell's  series.  With  statistics  like  these  in  the  litera- 
ture, there  is  no  doubt  that  definite  and  compelling  indications  are  necessary 
to  justify  operations  during  pregnancy. 

Myomectomy  appears  to  us  as  a  surgical  curiosity  with  rather  a 
narrow  field  for  the  treatment  of  fibroids  complicating  pregnancy, 
because  it  is  most  difficult  to  perform  successfully  in  the  class 
of  cases  in  which  interference  is  most  frequently  demanded  (pelvic 
impaction)  ;  as  well  as  the  fact  that  subsequent  adhesions  are  almost 
the  rule;  and  there  is  the  ever  present  possibility  that  the  scar  may  rup- 
ture during  labor  in  the  event  that  the  case  escapes  abortion  and  comes 
to  term.  Yet,  in  spite  of  all  theoretical  objections,  the  operation  has 
enjoyed  wide  vogue.  Tumors  of  fifteen,  sixteen,  and  seventeen  pounds 
have  been  removed  successfully  (Netzel,  Schorenz,  and  Edgar). 
Abortion  has  been  reported  in  less  than  one-fourth  of  the  cases ;  thus, 
Turner  reported  that  17^2  per  cent  aborted  in  44  myomectomies 
(1890-1900)  ;  Thumin,  28.4  per  cent  aborted  in  102  cases  (1885-1900) ; 
Le  Maire,  26.4  per  cent  aborted  in  93  cases  (1892-1901);  Carstens, 
29.1  per  cent  aborted  in  150  cases  up  to  1909;  Troell,  23.9  per  cent,  in 
157  cases  (1900-1909).  A  review  of  these  figures  indicates  that  cases 
should  be  carefully  selected  for  myomectomy  and  that  none  should  be 
operated  without  compelling  indications. 


CHAPTER  VII 
ADENOMYOMA  OF  THE  UTERUS  AND  OTHER  PELVIC  STRUCTURES 

Definition — Frequency — Etiology — Wolffian  theory — Miillerian  theory — Adenomyoma  of 
the  uterus — Cullen's  classification — Appearance  of  growth — Microscopically — Subperi- 
toneal  and  intraligamentous  adenomyoma — Submucous  adenomyoma — Cervical  adeno- 
myoma — Degenerations  of  uterine  adenomyoma — Cyst  formation —Carcinoma — Sar- 
coma— Tuberculosis — Condition  of  tubes  and  ovaries  in  adenomyoma — Symptoms  of 
uterine  adenomyoma — Physical  findings — Diagnosis — Prognosis — Treatment — Other 
forms  of  adenomyoma  —  Adenomyoma  of  the  rectovaginal  septum  —  Symptoms  — 
Physical  signs — Treatment. 

Adenomyoma  forms  a  distinct  class  of  fibroids.  It  is  composed  of 
glandular  elements  imbedded  in  fibromyomatous  tissues.  Occasionally, 
the  growth  is  diagnosed  prior  to  operation  because  of  distinctive  symp- 
tomatology and  clinical  findings.  Adenomyoma  may  be  found  in  any 
part  of  the  uterus,  the  tubes,  ovaries,  round  ligament  or  rectovaginal 
septum.  While  the  female  pelvic  organs  contain  most  of  these  tumors, 
they  have  been  observed  in  other  parts  of  the  body,  bowel,  stomach, 
gall-bladder,  kidneys,  etc. 

Frequency. — The  fact  that  fibroids  could  contain  glandular  tissue 
has  been  known  for  many  years.  As  early  as  1884,  Schroeder,  Herr 
and  Grosskopf  collected  100  such  cases.  Yet  these  tumors  were  not 
recognized  universally  as  a  distinct  type  until  von  Recklinghausen,  in 
1896,  focused  attention  upon  them,  since  when  they  have  been  the 
subject  of  much  investigation. 

There  are  comparatively  few  reports  which  indicate  the  frequency 
of  the  disease.  The  great  majority  of  the  tumors  have  been  discovered 
accidentally  in  the  laboratory  in  the  routine  examination  of  fibroids 
after  their  removal.  The  only  comprehensive  report  is  given  by  Cullen, 
who,  in  1908,  reported  that  5.7  per  cent  of  1,283  fibroids  which  came 
under  his  observation  were  proved  to  be  adenomyomata.  It  may  be 
possible  that  this  percentage  is  lower  than  the  actual  occurrence,  since 
the  presence  of  adenomyoma  can  be  excluded  only  when  the  entire 
fibroid  has  been  cut  into  thin  cross  sections,  and  subjected  to  micro- 
scopic study.  Because  of  the  enormous  labor  entailed  by  such  a  pro- 
cedure, only  the  more  suspicious  cases  were  so  treated  in  Cullen's 
laboratory. 

Etiology. — The  etiology  is  unknown,  although  usually  ascribed  to 
congenital  causes. 

163 


1 64  PELVIC   NEOPLASMS 

In  the  absence  of  definite  etiology,  investigators  have  confined  their 
studies  to  the  origin  of  the  epithelium.  The  majority  believe  that  the 
tumor  is  a  true  adenoma,  and  is  composed  essentially  of  epithelium,  and 
that  the  muscular  elements  are  secondary.  Others  believe  that  it 
differs  from  an  ordinary  fibroid  only  in  that  there  is  a  secondary  exten- 
sion of  glandular  tissue  from  the  endometrium  into  the  fibroid  mass. 
Von  Recklinghausen  recognized  two  types  of  tumors  classed  according 
to  the  origin  of  the  epithelium.  He  based  his  opinion  on  the  examina- 
tion of  34  uterine  and  tubal  adenomyomata.  In  one  he  considered  that 
the  epithelial  elements  were  derived  from  portions  of  the  original 
wolffian  bodies  which  were  pinched  off  in  early  fetal  life  and  after 
remaining  long  dormant  developed  into  the  glandular  structures.  This 
type,  he  believed,  was  situated  in  the  periphery  of  the  uterus  and  in  the 
tube.  In  the  other  type,  the  glandular  elements  arose  from  the  uterine 
mucosa.  He  considered  that  the  latter  cases  were  rare,  since  he  could 
demonstrate  a  connection  between  the  uterine  mucosa  and  the 
glandular  spaces  of  the  tumor  in  but  a  single  instance.  He  studied  23 
uterine  tumors.  In  the  great  majority  of  the  larger  growths,  he  found 
a  characteristic  arrangement  of  the  glandular  tissue.  There  was  one 
main  canal,  into  one  side  of  which  ran  many  subsidiary  tubules  which 
radiated  outward  like  the  sticks  of  a  fan.  The  tubules  were  close 
together  like  those  of  a  kidney.  There  were  also  numerous  cystic 
dilatations  in  the  secondary  tubules  which,  since  they  were  situated  in 
the  periphery,  presented  as  a  medullary  zone.  The  whole  picture 
suggested  the  possibility  that  the  epithelial  elements  originated  from 
the  wolffian  bodies,  a  view  which  was  strengthened  by  the  fact  that 
nearly  all  such  cases  were  found  near  the  tube  and  on  the  posterior 
surface  of  the  uterine  wall;  in  other  words,  near  the  site  of  the  wolffian 
bodies.  Von  Recklinghausen's  theory  was  presently  adopted  by  Pick, 
Breus,  Voigt,  Pfannenstiel,  Kronig,  and  others. 

In  marked  contrast  to  this  theory  is  Cullen's  view  that  the  epithelial 
elements  are  derived  from  the  glands  of  the  endometrium.  This  ob- 
server, in  1903,  presented  a  monograph  based  upon  the  study  of  22 
cases,  all  of  which  were  studied  by  serial  sections.  In  nearly  all  the 
cases,  the  glands  of  the  tumor  were  found  to  be  continuous  with  those 
of  the  endometrium.  The  epithelium  of  the  tumor  resembled  that  of 
the  uterine  glands  and  often  presented  areas  of  blood  which  suggested 
that  these  detached  islets  of  uterine  mucosa  carried  on  the  menstrual 
function.  In  1908,  Cullen  presented  an  extensive  monograph  based 
upon  a  study  of  56  cases  of  diffuse  adenomyomata  of  the  uterus.  The 
continuity  of  epithelium  between  endometrium  and  tumor  was  demon- 
strated by  serial  sections  in  55  of  the  56  cases.  Cullen's  hypothesis 
appeared  strengthened  by  the  case  reported  by  Whitridge  Williams  in 
which  the  uterus  of  a  woman  dying  shortly  after  labor  contained 
decidual  areas  in  the  glands  of  a  diffuse  adenomyoma.  Similar  findings 


ADENOMYOMA  OF  THE  UTERUS  165 

in  an  adenomyoma  complicated  by  tubal  pregnancy  were  observed  by 
Cullen. 

The  predisposing  causes  for  adenomyoma  are  not  known.  The  majority 
are  inclined  to  the  belief  that  the  condition  is  favored  by  a  preexisting 
chronic  inflammation  of  the  endometrium.  Chiari,  von  Franque, 
Legtien,  Marien,  and  others,  have  advocated  this  theory,  at  least  in 
part.  Others  lay  stress  only  on  mechanical  factors  and  consider  that 
the  opportunity  for  inucosal  invasion  is  brought  about  chiefly  by 
gestation  and  labor. 

Some  see,  in  the  extension  of  the  uterine  mucosa  into  the  fibroid 
tissue,  an  example  of  epithelial  heterotopy,  a  term  applied  by  Robert 
Meyer  to  characterize  a  nonmalignant  invasion  by  an  epithelial  mem- 
brane. They  associate  this  process  with  the  result  of  inflammation  and 
regard  it  as  a  healing  process  after  cell  injury  and  degeneration. 

Iwanoff,  in  1898,  advocated  the  view  that  the  glandular  structures 
were  derived  from  the  serosa  by  metaplasia.  He  also  saw  an  inflam- 
matory process  as  a  predisposing  condition,  under  which  stimulant  the 
peritoneal  epithelium  proliferates  and  sends  down  buds  of  cells  into  the 
subadjacent  tissues.  These  then  proliferate  and  form  branching  tubular 
adenomatous  processes.  He  states  that  the  metaplasia  of  cells  is  so 
complete  that  the  crypts  are  lined  by  columnar  epithelium,  and  that  the 
appearance  is  indistinguishable  from  one  derived  from  the  invasion  of 
a  true  mucous  membrane.  He  also  argued  that  the  connective  tissue 
adjacent  to  the  adenomatous  processes  changes  in  character  as  a  result 
of  inflammation  and  becomes  the  cytogenous  tissue  which  is  one  of  the 
chief  features  of  the  adenomatous  growth.  He  adduces  sections  show- 
ing the  change  to  support  his  view.  Sitzenfrey,  and  others,  have  pre- 
sented similar  findings.  At  the  present  time,  it  does  not  seem  as  if  all 
the  cases  of  adenomyoma  could  be  explained  by  one  theory.  There  is 
no  doubt,  however,  but  that  the  comprehensive  studies  of  Cullen  prove 
that  nearly  all  cases,  at  least  of  diffuse  adenomyomatous  growths  of 
the  uterus,  are  derived  from  aberrant  uterine  tissues. 


ADENOMYOMA   OF   THE   UTERUS 

The  following  classification  is  given  by  Cullen:  (i)  adenomyoma 
in  a  uterus  of  relatively  normal  contour;  (2)  subperitoneal  and  intra- 
ligamentous  forms;  and  (3)  submucous  growths. 

Adenomyoma  in  a  Uterus  of  Relatively  Normal  Contour. — The 
uterus  is  rarely  enlarged  in  these  cases  to  more  than  three  times  its 
normal  size.  Adhesions  are  usually  present  and  may  be  so  dense  that 
the  removal  of  the  uterus  is  often  attended  with  much  difficulty.  The 
size  of  the  tumor  varies,  although  it  may  be  so  extensive  as  to  involve 
one  side  of  the  uterine  wall.  The  posterior  wall  is  more  commonly 


i66 


PELVIC  NEOPLASMS 


involved,  although  the  tumor  may  be  present  on  the  anterior  side. 
When  the  growth  is  developed  almost  entirely  in  one  wall,  that  side  of 
the  organ  is  unusually  thick.  On  section  of  the  uterus,  the  diagnosis 
may  be  made  macroscopically.  The  characteristic  features  are  a  uni- 
form increase  in  density  without  evidence  of  a  circumscribed  tumor  and 
the  presence  of  the  adenomatous  processes  which  are  visible  to  the 


Cervical' Canal 


FIG.   56. — CYSTIC  ADENOMYOMA   WITH  NUMEROUS  NODULES  AND    SUBPERITONEAL    CYSTS 

(Kelly). 

naked  eye.  The  endometrium  is  usually  normal,  but  may  be  hyper- 
trophied  or  occasionally  attenuated.  The  adenomatous  growth  ex- 
tends to,  but  not  into,  the  endometrium.  The  other  muscular  coats 
are  usually  normal.  The  tumor  itself  is  of  variable  thickness  and 
appears  as  a  mass  of  coarsely  fibrillated  fibers  arranged  in  whorls,  in 
which  there  are  scattered  areas  of  a  homogeneous  translucent  tissue 
resembling  mucous  membrane.  Cystic  spaces  are  occasionally  found 
in  these  areas,  although  they  are  seldom  of  considerable  size.  The 


ADENOMYOMA  OF  THE  UTERUS  167 

glandular  areas  frequently  present  A  brownish  discoloration  which  in 
the  cystic  zone  may  be  seen  to  be  due  to  a  chocolate-colored  fluid. 
Small  fibroids  may  be  present  in  other  parts  of  the  uterine  wall.  They 
stand  out  as  pale  and  more  definitely  circumscribed  and  offer  a  strong 
contrast  to  the  diffuse,  pinkish,  hyperplastic  areas  which  are  found  in 
the  adenomyoma. 

Microscopically,  the  growth  is  seen  to  be  composed  of  fibromyomatous 
tissue  in  which  are  imbedded  glandular  structures.  The  former  differs 
from  that  usually  found  in  fibroids  only  in  that  there  is  no  definite 
encapsulation,  since  the  tissue  merges  gradually  into  the  surrounding 
muscular  wall.  The  glandular  tissues  present  as  irregular  masses  of 
varying  size  and  shape  which  may  be  scattered  throughout  the  tumor 
but  usually  are  more  abundant  near  the  uterine  cavity.  The  glands 
suggest  those  of  the  normal  endometrium,  although  their  outline  is 
more  'irregular.  They  are  of  tubular  form,  and  frequently  open  into 
one  chief  canal  which  later  may  become  a  cyst  of  some  size.  The  glands 
are  imbedded  in  cellular  tissue  as  in  the  normal  endometrium.  The 
arrangement  of  the  glandular  tubules  is  not  uniform.  Occasionally, 
they  enter  the  terminal  canal  only  on  one  side,  presenting  an  outline 
similar  to  that  seen  in  the  ducts  of  the  glomeruli  of  the  mesonephron. 
This  picture  strongly  suggests  tissues  of  the  wolffian  body.  Yet  Cullen 
demonstrated  their  continuity  with  the  endometrium  in  practically 
every  case.  The  ducts  are  lined  with  a  single  layer  of  ciliated  columnar 
epithelium,  containing  an  oval  vesicular  nucleus  in  the  base  of  each  cell. 
The  stroma  also  resembles  the  endometrium  and  contains  thin-walled 
blood  vessels.  The  cyst  spaces  of  the  central  duct  contain  old  blood 
and  pigmented  cells  which  Cullen  believes  are  the  result  of  menstrual 
changes. 

Subperitoneal  and  Intraligamentous  Adenomyoma. — These  forms 
develop  by  processes  identical  to  those  noted  in  the  production  of  sim- 
ilar types  in  ordinary  fibroids.  A  tumor  which  develops  above  the 
middle  of  the  uterus,  and  grows  outward  underneath  the  peritoneal 
investment  of  the  uterus,  constitutes  a  subperitoneal  tumor.  In  con- 
trast, a  growth  which  originates  below  this  point  and  grows  to  the 
lateral  side  of  the  uterus  is  likely  to  develop  between  the  folds  of  the 
broad  ligament,  when  it  is  termed  intraligamentous. 

Subperitoneal  adenomyoma  may  vary  in  size  and  shape.  They  are 
usually  sessile  and  rarely  present  with  a  definite  pedicle.  Cullen  found 
8  subperitoneal  growths  in  his  56  tumors.  In  contrast  with  diffuse 
types  of  adenomyoma  in  a  uterus  of  normal  outline,  the  subperitoneal 
adenomyomata  are  usually  cystic.  The  cysts  vary  in  size  from  micro- 
scopic areas  to  masses  which  practically  fill  the  tumor.  They  are 
usually  multiple  and  contain  chocolate-colored  fluid.  They  present 
different  colors,  depending  on  the  amount  of  myomatous  tissue  which 
they  contain.  As  a  rule,  they  are  dark  colored.  Occasionally,  the 


1 68  PELVIC  NEOPLASMS 

cystic  growth  can  be  seen  shining  through  the  peritoneal  coat  of  the 
uterus.  There  is  no  doubt  but  that  many  of  these  cases  are  mistaken 
for  peritoneal  inclusion  cysts.  The  masses  are  usually  but  not  uni- 
formly covered  by  adhesions.  The  cyst  walls  are  composed  of  fibro- 
myomatous  tissue  lined  with  a  well-defined  membrane,  whose  epithelial 
elements  are  cylindrical,  ciliated  epithelium  in  a  single  layer. 

The  intraligamentous  forms  are  similar  to  the  subperitoneal  vari- 
ety, although  the  cysts  may  attain  extremely  large  size.  Breus 
described  one  which  contained  seven  liters  of  fluid.  Lockyer  believes 
that  many  of  these  growths  may  arise  from  the  wolffian  system,  and 
possibly  Meyer's  theory  may  explain  others,  although  Cullen's  micro- 
scopic pictures  cannot  be  regarded  lightly. 

Submucous  Adenomyoma. — These  are  the  rarest  forms  of  uterine 
adenomyoma  and  differ  from  those  previously  described  in  that  they 
present  as  polyps.  The  structure  of  this  form  is  identical  with  that  of 
the  diffuse  type.  Cullen  believes  that  they  develop  as  a  diffuse  growth 
and  become  polypoid  as  a  result  of  uterine  contraction  which  finally 
forces  them  from  their  bed  just  as  the  ordinary  fibroids  may  be  ex- 
cluded from  the  uterus.  Cyst  formation  is  rare,  possibly  because  of  the 
pressure  exerted  by  the  uterus  on  all  sides  of  the  tumor.  The  mucosal 
covering  varies,  just  as  it  does  in  the  ordinary  fibromyomatous  polyps. 

Cervical  Adenomyoma. — This  type  is  occasionally  encountered.  It 
presents  in  various  forms,  depending  upon  the  direction  of  the  tumor's 
growth.  Rarely  it  grows  into  the  cervical  canal  and  attains  consider- 
able size.  Landau  and  Pick  have  described  a  case  in  which  the  cervical 
canal  was  entirely  obliterated  by  the  tumor.  The  histologic  picture  is 
similar  to  that  of  the  preceding  forms,  save  that  the  glandular  areas 
resemble  cervical  glands.  Sometimes  growths  which  develop  from 
beneath  the  uterine  endometrium  extend  downward  below  the  internal 
os.  They  should  not  be  confused  with  adenomyoma  of  the  cervix. 

Degenerations  of  Uterine  Adenomyoma. — Degenerations,  with  the 
exception  of  cyst  formation,  are  very  unusual  in  this  class  of  tumors. 
This  is  undoubtedly  due  to  the  good  circulation  of  the  growth.  As 
has  been  noted  above,  the  cysts  are  due  to  the  deposit  of  menstrual 
fluid  in  the  pockets  of  the  growth.  Their  ultimate  size  is  dependent 
upon  the  resistance  offered  by  the  uterine  wall  and  the  pressure  that  is 
exerted  by  the  menstmal  secretion. 

Carcinoma  is  a  rare  degeneration  of  the  adenomatous  tissue.  It  may 
originate  in  the  epithelial  elements  of  the  tumor  or  may  extend  into  the 
mass  as  a  secondary  invasion  from  a  carcinoma  which  has  been  primary  in 
the  uterus.  Primary  carcinomatous  degeneration  has  been  recorded  by 
Roily,  Babescu,  Schwab,  Dillman  (2  cases),  von  Recklinghausen  (3  cases), 
while  combined  cancer  of  the  uterus  and  adenomyoma  have  been  described 
by  a  number  of  men.  Cullen  cites  6  cases  of  epithelioma  of  the  cervix, 
together  with  diffuse  adenomyoma  of  the  body  of  the  uterus.  Also  2  cases 


ADENOMYOMA  OF  THE  UTERUS  169 

of  diffuse  adenomyoma  in  conjunction  with  adenocarcinoma  of  the  body. 
Griinbaum  describes  a  case  of  cancer  of  the  body  and  adenomyoma  of  the 
cornua. 

Sarcoma  is  infrequently  associated  with  adenomyoma.  Iwanoff,  Bau- 
ereisen,  and  Kaufmann  each  have  described  cases. 

Tuberculosis  is  more  commonly  observed  as  a  complication.  In  fact, 
tuberculous  lesions  have  been  so  frequently  found  in  salpingitis  isthmic 
nodosa  that  many  authors  have  come  to  regard  the  tubercle  bacillus  as  an 
etiologic  factor  in  adenomyoma.  This  is  not,  however,  substantiated  by 
Meyer.  Tuberculous  degeneration  of  adenomyoma  has  been  recorded  by 
von  Recklinghausen,  Lichtenstein,  Hoelsi,  Archambauld,  Pierce,  and  Lan- 
dau, while  Lockyer  and  others  have  noted  the  association  of  adenomyoma 
and  tuberculosis  of  the  fallopian  tubes. 

Condition  of  the  Tubes  and  Ovaries  in  Adenomyoma. — Cullen 
described  the  condition  of  the  tubes  and  ovaries  in  45  cases.  They 
were  normal,  in  15  cases.  Numerous  adhesions  were  present  in  30,  due,  he 
believed,  to  a  mild  degree  of  pelvic  peritonitis  caused  by  the  diffuse 
adenomyomatous  growth.  Inflammatory  changes  were  noted  in  one 
half  of  Landau's  cases.  Polano  and  Kudoh  found  adhesions  in  89.5 
per  cent  of  cases  (72  cases  in  the  series).  Cullen  found  adhesions  on 
the  uterus  in  24  of  49  cases.  They  were  usually  only  on  the  posterior 
surface.  The  literature  indicates  that  adenomyoma  is  far  more  fre- 
quently associated  with  pelvic  peritonitis  than  is  the  ordinary  fibroid. 

Symptoms  of  Uterine  Adenomyoma. — The  symptoms  vary  accord- 
ing to  the  size  and  location  of  the  growth  and  the  condition  of  the 
adnexa.  The  symptoms  are  usually  hemorrhage  and  pain. 

Hemorrhage  is  common  and  usually  presents,  at  first,  as  a  prolonged 
menstrual  period.  With  the  development  of  the  tumor,  the  bleeding 
may  be  so  great  as  to  occasion  alarm.  The  hemorrhage  is  readily 
explained  when  we  take  into  consideration  the  greatly  increased  area 
of  uterine  mucosa,  so  that  both  the  endometrium  of  the  uterine  cavity 
and  the  patches  scattered  throughout  the  tumor  share  in  the  process. 

The  pain  may  be  a  dull  ache,  or  it  may  be  grinding  in  character.  In 
the  cases  first  presenting  symptoms,  the  pain  is  generally  limited  to 
the  uterus  but  may  be  referred  to  the  back  and  legs.  It  is  thought 
that  the  pain  results  from  nature's  effort  to  expel  the  tumor  as  a  foreign 
body  at  a  time  when  it  is  engorged  with  blood. 

Lcukorrhca  is  not  ordinarily  seen  in  cases  presenting  only  adenomyoma. 
If  there  are  old  foci  of  infection,  it  may  be  present,  but  not  necessarily 
as  a  result  of  the  growth.  Intermenstrual  discharge  is  very  rare. 

Physical  Findings. — The  physical  findings  are,  as  a  rule,  not  dis- 
tinctive of  adenomyoma,  but  are  those  of  the  ordinary  fibromyoma 
complicated  by  pelvic  inflammatory  disease.  The  type  of  tumor  that 
preserves  the  normal  outline  of  the  uterus  may  present  only  an  en- 
larged uterus.  Since  dense  adhesions  are  not  the  rule  in  these  cases, 


170 


PELVIC   NEOPLASMS 


the  uterus  may  be  freely  movable.  Lockyer  emphasizes  the  fact  that 
ordinary  fibroids  are  usually  present  in  association  with  these  tumors. 
The  intraligamentous  forms  are  more  firmly  fixed  in  the  pelvis  than 
are  the  ordinary  fibroids.  Occasionally,  they  may  simulate  a  pelvic 
abscess.  Tumors  of  the  rectovaginal  septum  may  readily  be  confused 
with  pelvic  inflammatory  diseases  or  with  rectal  carcinoma. 


FIG.  57. — ADENOMYOMA  OF  POSTERIOR  UTERINE  WALL. 

Diagnosis. — Generally  speaking,  the  case  is  regarded  as  an  ordinary 
fibroid  until  it  has  been  cut  open  in  the  operating  room.  Occasionally, 
however,  cases  present  certain  features  which  are,  at  least,  strongly 
suspicious  of  this  condition.  Freund,  in  1896,  stated  that  these  tumors 
presented  a  definite  clinical  picture  by  which  they  could  be  diagnosed. 
Cullen  agrees  with  this  view  and  states  that  while  he  failed  to  detect  it 
clinically  in  the  early  stages  of  his  investigation,  he  is  now  convinced 
that  diffuse  adenomyoma  of  the  uterus  presents  symptoms  so  sug- 
gestive that  hospital  assistants  may  at  least  suspect  the  condition.  He 
emphasizes  that  when  a  physical  examination  has  disclosed  an  enlarged 
adherent  uterus,  the  following  clinical  facts  point  strongly  to  adeno- 


ADENOMYOMA  OF  THE  UTERUS  171 

myoma:  (i)  the  bleeding  is  usually  confined  to  the  menstrual  period; 
(2)  there  is  commonly  much  pain  during  menstruation  referred  to  the 
uterus;  (3)  there  is  usually  no  intermenstrual  discharge  of  any  kind; 
and  (4)  the  uterine  mucosa  is  perfectly  normal  and  is  rather  thick, 
although  this  finding  can  be  observed  only  after  curettage. 

Freund  urged  that  patients  presenting  uterine  adenomyoma  usually 
presented  a  history  of  (a)  a  sickly  childhood;  (b)  delayed  onset  of  menstru- 
ation; (c)  profuse  and  painful  periods;  (d)  irregular  hemorrhages,  pelvic 
peritonitis  and  marked  anemia;  (<?)  bodily  functions  impaired  so  that  ordi- 
nary activities  are  more  or  less  impossible. 

These  views  are  not  supported  by  the  majority  of  other  observers. 
Griinbaum  combated  it  from  study  of  a  series  of  20  cases  in  Landau's 
cases.  Polano  and  Kudoh  obtained  no  corroboration  from  a  study  of 
100  cases.  The  average  age  of  Landau's  cases  was  forty-one  years. 
Forty-five  per  cent  of  Polano's  66  operative  cases  were  in  the  fifth 
decade.  Volk  recorded  a  case  in  a  virgin,  aged  twenty-five  years. 
Treub  operated  cases  of  sixty-nine  and  eighty-five  years.  Polano 
found  that  menstruation  was  established  between  twelve  and  nineteen 
years,  that  it  was  regular  in  63  per  cent  and  irregular  in  37  per  cent. 
It  was  excessive  in  62  per  cent,  normal  in  amount  in  18  per  cent,  and 
scanty  in  18  per  cent.  Only  9  of  Griinbaum's  20  cases  complained  of 
severe  pelvic  pain  during  menstruation.  Ten  of  Griinbaum's  cases 
were  very  well  developed  and  infantilism  was  rare.  Only  one  instance  gave 
a  history  of  delayed  onset  of  menstruation.  In  our  experience,  uterine 
fibroids  are  often  associated  with  pelvic  inflammatory  disease.  This 
group  of  cases  is  many  times  more  frequent  than  that  of  the  adeno- 
myoma, and  the  symptoms  are  practically  identical.  In  consequence, 
we  very  often  suspect  adenomyoma  and  find  at  the  operation  that  the 
condition  is  only  a  fibroid  complicated  with  inflammation.  We  believe, 
therefore,  that  an  opinion  expressed  before  operation  amounts  only  to 
a  possibility. 

Prognosis. — The  prognosis  without  operation  is  undoubtedly  worse 
than  in  ordinary  fibroids,  because  the  growth  which  causes  hemorrhage 
and  pain  is  usually  complicated  by  pelvic  inflammatory  processes. 
There  is  no  doubt  but  that  curetting  and  medical  treatment  aggravates 
the  conditions.  The  danger  in  neglected  cases  is  from  hemorrhage, 
which  in  at  least  one  case,  that  of  Fritz  Volk,  led  to  death.  Because 
adenomyoma  is  better  nourished  than  the  ordinary  fibroid,  it  is  not 
liable  to  degenerative  changes.  There  are  no  records  of  sloughing  or 
gangrenous  adenomyoma,  although  cystic  formation  may  occur  to  an 
extreme  degree.  While  adenomyoma  may  predispose  to  carcinoma, 
this  degeneration  is  not  very  frequent.  The  intimate  relationship  with 
pelvic  peritonitis  is  of  great  importance  from  the  viewpoint  of  prog- 
nosis. The  association  of  inflammations  of  the  adnexa,  tumors  of  the 
ovary,  pelvic  peritonitis,  parametritis,  and  infiltration  in  the  bowel, 


172  PELVIC  NEOPLASMS 

tuberculosis,   carcinoma   and   sarcoma,    emphasize   the   importance  of 
surgical  removal. 

Treatment. — The  treatment  is  operative,  since  the  literature  clearly 
shows  that  medical  and  palliative  treatment  only  aggravates  the  con- 
dition. Hysterectomy  is  the  method  of  choice,  since  the  growths  are 
not  definitely  encapsulated  and  consequently  cannot  be  enucleated,  and 
because  adhesions  and  adnexal  disease  are  so  common  that  conserva- 
tive work  is  likely  to  be  followed  by  an  increase  in  adhesions. 


OTHER    FORMS    OF   ADENOMYOMA 

Adenomyomata  of  the  uterine  horn  and  the  round  ligament,  the 
broad  ligament,  the  ovarian  ligament,  the  ovary,  and  the  rectogenital 
septum  have  also  been  described.  In  their  essential  features,  they  do 
not  differ  from  the  preceding  types  with  the  exception  of  the  adeno- 
myoma  of  the  rectogenital  septum.  The  adenomyomata  of  the  round 
ligament  are  described  under  tumors  of  the  round  ligament  (page  383). 

Adenomyomata  of  the  Rectovaginal  Septum. — These  are  diffuse 
growths,  consisting  of  nonstriated  muscle  and  fibrous  tissue  containing 
small  areas  of  mucosa  scattered  throughout  a  mass  which  is  present 
in  some  part  of  the  rectovaginal  wall.  They  vary  in  size,  although  the 
majority  are  small.  Heineberg,  in  1919,  reviews  the  literature  and 
tabulates  47  cases.  Cullen  believes  that  they  may  start  in  the  vaginal  wall, 
just  behind  the  cervix,  and  spread  in  a  diffuse  and  irregular  manner 
over  the  anterior  rectal  wall  into  one  or  both  broad  ligaments,  until 
they  finally  present  as  a  large  mass  to  which  are  attached  nearly  all 
the  structures  of  the  pelvis.  Clinically,  they  present  in  two  types,  one, 
the  small  tumor  lying  free  in  the  rectovaginal  septum,  and  the  other 
which  is  firmly  adherent  to  the  pelvic  organs,  "binding  them  like  glue." 
Heineberg  believes  that  the  nature  and  extent  of  the  vaginal  involve- 
ment does  not  bear  any  relationship  to  the  size  of  the  tumor. 

The  minute  anatomy  of  these  cases  differs  in  no  essential  feature 
from  the  adenomyomata  previously  described.  The  chief  interest  lies 
in  their  symptomatology  and  treatment,  since  they  may  extend  into  the 
rectal  wall  or  present  in  the  vagina  beneath  the  cervix,  cause  symptoms 
which  may  be  confounded  with  cancer  and  constitute  a  mass,  the 
removal  of  which  presents  considerable  technical  difficulty. 

Lockyer  states  that  the  majority  of  students  at  the  present  time 
regard  the  tumor  as  an  inflammatory  product  and  not  as  a  true  neo- 
plasm. Pick,  Pfannenstiel,  von  Herf,  and  others  favor  the  origin  from 
the  wolffian  system,  while  Fiith,  Kleinhans,  Schwab,  and  others  agree 
with  Cullen  that  the  gland  elements  are  derived  from  the  endometrium. 
Meyer,  Raspini,  Sitzenfrey,  and  Amann  are  among  those  who  support 
the  serosa  theory. 


ADENOMYOMA  OF  THE  UTERUS  173 

Symptoms. — In  addition  to  an  increase  in  the  amount  and  duration 
of  flow,  there  may  be  bleeding  from  the  rectum.  Pain  is  common,  as 
are  pressure  symptoms  in  the  rectum.  The  pain  is  confined  to  the 
lower  abdomen.  The  symptoms  are  increased  during  menstruation, 
and  persist  after  the  flow  has  ceased,  features  which  should  differen- 
tiate it  from  ordinary  dysmenorrhea. 

The  physical  signs  are  strongly  suggestive.  There  is  usually  a  dense 
nodular  induration  or  a  flattened  mass  present  in  the  upper  part  of  the 
posterior  vaginal  wall.  The  mass  is  usually  closely  adherent  to  the 
rectal  wall.  When  high  up,  it  is  attached  to  the  supravaginal  cervix. 
Since  the  growth  extends  along  the  pelvic  partitions,  it  involves  the 
uterosacrals,  broad  ligaments,  and  ultimately  presents  as  a  dense  pelvic 
mass,  strongly  suggesting  cellulitis.  The  characteristic  cysts  are  occa- 
sionally seen  shining  through  the  upper  portion  of  the  posterior  vaginal 
wall.  They  may  present  as  small,  bluish  points  or  project  as  polypoid 
masses.  The  vaginal  covering  may  be  lost  and  replaced  by  an  ulcer- 
ating mass  which  bleeds  easily.  The  rectal  examination  often  gives  a 
better  impression  of  the  tumor  than  does  the  vaginal.  The  rectum  is 
often  infiltrated  and  bleeds  easily.  There  are  yet  no  cases  in  which  the 
tumor  has  penetrated  the  rectal  wall. 

Treatment. — The  treatment  is  hysterectomy  with  the  removal  of  as 
much  of  the  infiltrated  tissue  as  is  possible.  There  is  considerable 
question  as  to  the  value  of  removing  part  of  the  rectal  wall  when  the 
tumor  has  invaded  that  structure.  There  are,  in  the  literature,  10 
cases  in  which  areas  from  4  centimeters  to  20  centimeters  in  length 
were  removed  from  the  rectum,  although  there  are  many  others  in 
which  there  was  no  recurrence,  even  though  small  areas  of  the  tumor 
were  left  in  the  infiltrated  rectal  wall.  Sitzenfrey  left  an  indurated 
bowel  but  no  recurrence  was  observed  even  after  ten  years.  He  dis- 
tinguished, however,  between  an  adenomyositis  of  the  rectum  and  a 
true  adenomyoma  of  that  structure  and  believed  that  the  latter  may 
deevlop  on  top  of  the  former.  As  a  result  of  his  study,  he  concludes 
that  the  infiltrated  type  (adenomyositis)  disappears  after  operation 
and,  if  there  is  no  stenosis  of  the  bowel,  resection  is  not  indicated.  In 
true  adenomyoma  of  the  bowel,  resection  is  indicated.  Filth's  case, 
and  those  of  Kleinhaus  and  Moraller,  showed  the  same  benign  char- 
acters even  though  a  lump  was  left  in  the  rectal  wall.  Rumpf's  case 
of  recto-uterine  growth  was  well  four  years  after  operation  without 
resection  of  the  rectum  and  Glockner's  case  two  years  after.  Meyer 
excised  nearly  the  whole  vaginal  wall,  which  was  riddled  with  gland 
tubules.  The  upper  portion  of  the  growth  could  not  be  removed,  since 
it  was  so  densely  adherent  to  the  rectum.  Yet  "cure  occurred  contrary 
to  expectation." 

As  opposed  to  this  conservative  view,  Cullen  states  that  an  early 
recognition  of  the  growth  is  necessary  if  there  is  to  be  a  safe  and  com- 


i74  PELVIC  NEOPLASMS 

plete  removal.  While  the  tumor  lacks  the  characteristics  of  a  malig- 
nant neoplasm,  as  evidenced  by  lack  of  metastases,  and  production  of 
toxins,  nevertheless,  it  menaces  by  the  chance  of  obstruction  of  the 
ureters  and  rectum  and  the  creation  of  dense  adhesions  in  the  pelvis, 
and  also  by  its  tendency  to  return  after  incomplete  removal.  Cullen 
advocates  a  resection  of  the  rectum,  together  with  the  uterus,  when- 
ever the  lumen  of  the  bowel  is  greatly  reduced,  followed  by  anas- 
tomosis. 


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YOUNG  AND  WILLIAMS.     The  Relations  of  Fibroids  to  Sterility.     Boston 

Med.  and  Surg.  Journ.     1911.     165:837.     Nov.  30. 


CHAPTER   VIII 

CARCINOMA  OF  THE     UTERUS;  CLASSIFICATION;  GENERAL  META- 
STASES;  SYMPTOMS  OF     CARCINOMA  OF  THE  CERVIX 

Frequency — Etiology — Cohnheim's  theory — Parasitic  theory — Symptoms — Disturbance  of 
nitrogen  balance — Heredity — Cancer  families — Predisposing  causes — Age — Classifica- 
tion of  uterine  cancer — Topographical — Histological — Morphological — Squamous-cell 
carcinoma  of  portio  vaginalis — Everting  type  of  cervical  canal — Inverting  type  of 
cervical  canal — Everting  and  inverting  types  of  body  of  uterus — Adenocarcinoma  of 
uterus — Cervix — Everting  and  inverting  types — Method  of  extension  of  cervical 
cancer — The  broad  ligaments — Body  of  the  uterus — Vagina — Pelvic  peritoneum — 
Urinary  system — Rectum — Adnexa — Lymph  nodes  —  General  metastases  —  Symptoms 
of  carcinoma  of  the  cervix — Percentage  of  operability — Leukorrhea — Hemorrhage — 
Clinical  course — Diagnosis — Differential  diagnosis — Prognosis. 

CARCINOMA  OF  THE  UTERUS 

Carcinoma  of  the  uterus  is  the  most  frequent  tumor  of  this  organ. 
Orth  states  that  it  forms  30  per  cent  of  all  carcinoma  in  women.  It 
caused  14.3  per  cent  of  the  31,000  deaths  from  malignancy  in  women 
in  the  United  States  in  1914.  Roger  Williams,  writing  in  1896,  stated 
that  one  in  thirty-five  of  all  the  women  over  thirty-five  years  of  age 
died  from  uterine  cancer  in  England  and  Wales  according  to  the  Regis- 
trar General's  statistics.  Kaufmann  found  that  cancer  of  the  uterus 
constituted  14.7  per  cent  of  the  cancers  in  both  men  and  women  in  the 
Basle  Institute,  and  15.6  per  cent  of  a  similar  series  in  Gdttingen. 

Frequency. — There  is  some  difference  of  opinion  as  to  whether 
uterine  cancer  is  the  most  common  cancer  met  in  women,  although  the 
majority  state  that  it  is.  Spencer  quotes  the  68th  annual  report  of  the 
Registrar  General  of  England  and  Wales  to  prove  that  it  is.  During 
the  years  1901  to  1905,  19,645  women"  died  of  cancer  of  the  uterus  in 
England  and  Wales,  in  contrast  to  14,308  cancers  of  the  breast  and 
12,048  cancers  of  the  stomach.  Birsch-Hirschfeld  also  placed  cancer 
of  uterus  first  in  order  of  frequency  in  the  malignant  diseases  of  women 
in  Germany.  In  Welch's  statistics  of  31,483  cancers  of  men  and  women, 
29.5  per  cent  were  uterine  and  21.4  per  cent  of  the  stomach.  The 
figures  were  all  the  more  remarkable  because  the  stomach  cancers 
include  those  in  both  sexes.  Roger  Williams  states  that,  according  to 
his  compilations,  carcinoma  of  the  breast  is  more  common  than  uterine 
cancer.  Dublin,  collecting  mortality  statistics  for  the  Metropolitan 
Life  Insurance  Company,  found  that,  in  the  United  States  during  the 

176 


CARCINOMA  OF  THE   UTERUS  177 

six-year  period — 1911  to  1916 — there  were  3,666  cancer  deaths,  which 
constituted  5.9  per  cent  of  the  total  mortality.  Carcinoma  of  the 
stomach  was  most  frequent  of  all  cancers,  37.6  per  cent  of  both  sexes; 
cancer  of  the  female  genital  tract  caused  20.9  per  cent  of  deaths  of 
both  sexes.  It  constituted  28.6  per  cent  of  the  cancer  deaths  in  white 
women.  From  tabulations  of  7,882  cancers  in  women,  he  found  that 
cancer  of  the  female  genital  tract  was  responsible  for  25.3  per  cent 
of  the  deaths  per  100,000  in  white  women  and  for  37.9  per  cent  of  the 
deaths  per  100,000  in  colored  women. 

Many  believe  that  cancer  is  more  common  at  present  than  it  was 
formerly.  Roger  Williams'  statistics  show  that  i  of  129  deaths  from  all 
causes  in  1840  was  due  to  cancer  while,  in  1894,  it  had  risen  to  I  in  23, 
an  increase  of  more  than  500  per  cent.  Wilcox's  paper  is  interesting  in 
this  connection.  It  was  based  on  a  number  of  exhaustive  reviews  pub- 
lished since  1892,  and  included  the  excellent  study  of  the  Frankfort 
statistics  of  1890  to  1913  by  King  and  Newsholme.  Wilcox  states  that 
the  reported  cancer  mortality  seems  to  be  increasing  in  nearly  every 
part  of  the  world,  but  that  the  real  mortality  is  not  increasing  with  the 
rapidity  which  the  statistics  indicate.  He  feels  that  the  apparent 
increase  is  due  to  improvements  in  diagnosis  rather  than  to  an  actual 
increase,  since  cancer  is  now  recognized  in  situations  which  were  for- 
merly inaccessible  to  study  ;  and  that  a  proper  rearrangement  of  the  older  sta- 
tistics so  that  they  could  be  compared  properly  with  recent  compilations 
would  explain  away  more  than  half,  and  perhaps  all*  of  the  apparent 
increase  in  cancer  mortality.  There  are  also  other  factors  which  merit 
consideration.  It  seems  perfectly  rational  to  believe  that,  since  the 
mortality  attending  many  infectious  diseases  which  formerly  amounfecl 
to  plague  has  been  greatly  reduced,  many  more  women  nowadays  live 
to  the  age  at  which  they  are  liable  to  cancerous  growths.  The  relative 
frequency  of  carcinoma  of  the  uterus  has  been  reduced  in  recent  years 
because  of  better  diagnosis  in  pelvic  conditions.  Sarcoma,  myoma, 
carcinoma  of  the  vagina  and  ovaries  were  formerly  confused  with  car- 
cinoma of  the  uterus.  Now  they  are  more  likely  to  be  recognized  as 
clinical  entities.  • 

Etiology. — The  etiology  of  carcinoma  is  not  known.  There  are  a 
perfect  host  of  theories  to  account  for  the  condition.  Some  are  based 
on  clinical  observations,  others  on  careful  experimental  work,  and 
many  are  purely  philosophical  conjecture.  In  recent  time,  study  of 
cancer  is  carried  on  by  chemical  and  biological  investigation  both  of 
the  neoplasm  and  the  general  body  metabolism  of  the  host.  The  latter 
field,  while  relatively  new,  may  later  give  promising  results. 

The  theories  which  have  been  advanced  to  explain  the  origin  of  cancer 
come  under  a  number  of  headings. 

The  older  theory  of  Cohnhcim,  that  cancer  develops  by  the  proliferation 
in  an  atypical  manner  of  embryonic  inclusion  of  epithelial  elements,  which 


178  PELVIC  NEOPLASMS 

have  remained  dormant  for  a  long  period,  has  not  received  any  support  from 
histological  studies.  Yet  it  must  be  taken  into  consideration  with  nearly 
every  theory,  since  the  latter,  as  a  rule,  are  most  likely  to  come  under  the 
general  heading  of  predisposing  causes.  The  theory  has  not  been  accepted 
by  Cullen  and  a  number  of  other  investigators,  who  have  had  much  oppor- 
tunity for  studying  both  normal  and  diseased  uterine  tissues. 

The  parasitic  theory  has  been  advocated  by  a  number  of  investigators 
who  show  that  there  are  more  points  of  similarity  between  cancer  and  infec- 
tion than  seem  evident  on  casual  reflection.  Carcinoma  runs  a  definite 
clinical  course,  becomes  disseminated,  and  leads  to  constitutional  dis- 
turbances, just  as  infection  does.  There  is  also  a  constant  primary  local 
origin,  widespread  metastases,  and  a  definite  predisposing  condition  which 
antedates  the  growth  and  diminishes  the  resistance  of  the  affected  parts. 

The  various  predisposing  factors  are  grouped  as  trauma,  and  may  be  of 
a  mechanical,  chemical,  physical,  or  infectious  nature.  They  are  usually 
chronic.  Maud  Slye's  experiments  in  mouse  cancer  at  least  indicate  a 
transmissible  predisposition  for  mouse  carcinoma. 

Direct  contact  infection  is  noted  clinically  in  certain  forms  of  cancer, 
as  in  carcinoma  of  the  labia,  which  extends  directly  to  the  tissue  of  the 
opposite  side  with  which  it  approximates;  in  epithelioma  which  has  come 
on  the  lip  of  both  father  and  son  who  used  the  same  drinking  vessel';  in 
several  undoubted  cases  of  marital  infection;  by  the  frequent  occurrence 
of  carcinoma  in  certain  localities,  and  often  in  certain  houses.  Moreover, 
the  development  of  carcinoma  which  has  been  implanted  secondarily  during 
operation  seems  akin  to  infection  which  is  disseminated  in  like  manner. 
The  advocates  of  the  theory  hold  that  implantation  carcinoma  in  stitch-hole 
wounds  of  the  abdomen,  vulva  or  perineum  resulting  from  cells  which  have 
been  directly  transplanted,  indicates  a  lessened  immunity  to  the  develop- 
ment of  the  growth.  They  see  the  extension  from  cancer  of  the  jaws  to  the 
vocal  cords  and  lips  as  the  result  of  transference  of  live  tissues  by  a  process 
comparable  to  skin  grafting. 

Advocates  of  the  theory  point  out  that  all  the  specific  diseases  except 
carcinoma  are  admitted  to  be  exogenetic.  They  state  that  their  theory 
cannot  be  held  invalid  because  the  specific  organism  is  not  found,  since  the 
germs  of  many  acute  infections,  as  smallpox,  etc.,  have  not  been  discovered 
either.  The  majority  believe  that  carcinoma  is  due  to  an  ultra-microscopic 
organism  conveyed  in  the  tissues,  and  explain  the  different  varieties  of 
cancer  which  result  on  the  ground  of  various  reactions  of  various  cells. 
Many  have  claimed  to  have  found  the  cancer  parasite,  yet  the  Plimmer- 
blastomyces  and  Russell's  fuchsin  bodies  and  a  number  of  other  structures 
which  were  advanced  as  causal  factors  are  now  interpreted  as  degenerations 
of  various  kinds. 

The  probability  that  the  various  types  of  carcinoma  are  caused  by  a 
specific  virus  has  received  some  confirmation  by  the  work  of  Peyton  Rous. 
This  investigator  obtained  a  filtrable  agent  which  caused  sarcoma  in 


CARCINOMA  OF  THE  UTERUS  179 

chickens.  The  advocates  of  the  theory  state  that  immunity  may  develop  to 
transplanted  cancers  in  mice  just  as  in  infection,  as  has  been  proved  by 
Clowes,  Baesleck,  and  Gaylord  in  mice  that  have  been  inoculated  with 
breast  cancer.  Some  animals  recovered  with  disappearance  of  the  cancer, 
even  though  it  had  made  an  appreciable  growth,  and,  for  a  long  period 
after,  they  possessed  an  active  immunity,  shown  by  the  fact  that  they  could 
not  be  inoculated  with  the  same  tumor.  Occasionally  a  definite,  although 
slight,  passive  immunity  was  produced  by  the  following  experiment:  the 
blood  of  a  mouse,  which  had  recovered  after  noticeable  growth  of  a  trans- 
planted tumor,  was  mixed  with  a  small  portion  of  a  similar  cancer,  incu- 
bated for  a  period,  and  then  injected  into  another  susceptible  animal. 
Usually  there  was  no  growth.  Immunity  appears  to  develop  more  quickly 
if  the  cancer  is  injected  in  the  spleen.  Since  splenectomized  mice  are  more 
susceptible  to  cancer  than  are  normal  mice,  splenic  extract  has  been  sug- 
gested as  proper  therapeutic  means  of  combating  the  tumor. 

The  parasitic  theory  has  aroused  the  very  greatest  interest,  yet  at 
present  it  cannot  be  considered  as  proved.  The  actual  evidence  which 
has  been  accumulated  from  the  study  of  mouse  cancer  goes  little 
further  than  to  show  that  there  are  families  of  mice  in  which  cancer 
occurs,  and  to  prove  that  the  disease  can  be  transplanted  from  one 
mouse  to  another.  Our  present  knowledge  does  not  permit  us  to  judge 
the  extent  to  which  observations  of  cancer  in  mice  can  be  transferred 
to  the  problem  of  cancer  in  man. 

There  are  several  theories  which  have  been  developed  on  purely  philo- 
sophical grounds  that  seem  worthy  of  mention.  One  advances  the  view  that 
carcinoma  may  result  from  an  autoparasitism  in  which  local  accumulations 
of  lymphocytes  are  important  factors.  It  assumes  that  cell  growth  depends 
to  some  degree  upon  the  action  of  lymphocytes,  and  that  enzym'es  liberated 
from  the  nucleus  are  responsible  for  cell  division.  This  is  suggested  by  the 
fact  that  lymphocytes  predominate  in  the  blood  during  the  period  of  most 
active  growth,  and  shrink  in  number  when  the  body  has  approached  its 
potential  size.  The  fact  that  the  thymus  and  other  auxiliary  lymphoid  tissues 
atrophy  after  the  period  of  most  active  growth  probably  suggests  the  theory. 
Normally,  the  lymphocytes  and  their  enzymes  are  held  in  check  by  anti- 
bodies. Thus  they  do  not  stimulate  unduly  cell  division  during  chronic 
inflammations,  although  the  lymphocytes  are  concentrated  about  the  field. 
In  case  there  is  a  loss  of  the  lymphocytic  control,  because  antibodies  have 
not  developed  to  a  normal  degree,  as  a  result  of  hereditary  or  acquired 
factors,  there  would  ensue  a  rapid  proliferation  of  tissue  cells  with  the  for- 
mation of  a  cancer.  The  theory  recognizes  the  two  factors,  local  and  gen- 
eral. Locally,  the  cells  are  stimulated  by  lymphocytes  which  have  become 
concentrated  around  some  local  injury.  The  restraining  influence  of  anti- 
bodies maintains  a  normal  degree  of  cell  proliferation.  The  general  factor 
is  a  general  loss  of  lymphocytic  control,  because  of  failure  of  the  restrain- 


i8o  PELVIC  NEOPLASMS 

ing  antibodies  which  permits  lymphocytes  to  carry  cell  division  into  a  can- 
cerous stage. 

Another  theory  attempts  to  link  cancer  with  the  disturbance  of  the 
nitrogen  balance  in  body  tissue.  It  assumes  that  an  excess  of  nitrogen  com- 
pounds can  cause  an  excess  of  cell  division.  It  claims  that  nitrogen  is  liber- 
ated from  the  cell  as  a  result  of  a  stimulus  of  thermal,  mechanical,  or 
chronic  nature.  The  nitrogen  which  thus  escapes  causes  an  increased  in- 
stability of  the  protoplasm  of  adjoining  cells  which  proliferate  rapidly  as  a 
natural  consequence.  Carcinoma  would  be  expected  to  develop  more  fre- 
quently in  midlife,  since  the  glands  which  control  metabolism  are  under- 
going alterations  at  that  time.  In  case  the  functional  activity  of  the  spleen 
and  lymphatics  fails  coincidently,  there  results  an  accumulation  of  nitro- 
genous substances  in  the  blood  and  body  tissue  which  may  permit  an  ex- 
cessive cell  division  in  tissues  which  have  lost  their  resistance.  Some  have 
attempted  to  treat  cancer  on  the  basis  of  this  theory.  Shirlaw  advocates 
the  administration  of  spleen  or  lymph  gland  extracts,  or  their  combination, 
as  a  therapeutic  measure.  This  accords  with  the  fact  proved  by  animal 
experimentation  that  animals  that  have  had  their  spleens  removed  are  more 
susceptible  to  transplanted  cancer. 

Others  have  thought  that  an  excess  of  sodium  chlorid  in  the  blood  was 
responsible  for  the  rapid  proliferation  of  cells  as  far  as  the  carcinomatous 
stage,  and  suggest  the  use  of  potassium  nitrite  in  cancer  to  displace  the 
sodium  chlorid  that  is  present  in  excess  in  the  blood. 

There  is  a  difference  of  opinion  as  to  the  part  which  heredity  plays 
as  an  etiologic  factor.  The  older  authors  emphasized  its  importance,  but 
in  recent  years  it  has  been  minimized,  since  it  has  not  been  found  in  a  very 
large  proportion  of  cases;  yet  we  feel  that  one  cannot  spend  years  in  hos- 
pitals and  believe  that  family  histories,  as  usually  obtained,  are  of  much 
value.  Histories  in  the  larger  institutions  are  taken  usually  by  very  junior 
men  from  patients  who  in  America,  at  least,  know  little  of  their  family 
history.  The  patient  is  usually  asked  if  there  is  tuberculosis,  cancer  or 
insanity  in  the  family,  without  much  explanation  as  to  what  constitutes  the 
family.  If  cancer  causes  one  of  every  seventeen  deaths  (Dublin's  figures 
5.9  per  cent),  it  may  well  be  that  cancer  families  are  often  described  to 
unsuspecting  interns,  since  it  is  our  experience  that  few  hospital  patients 
know  the  life  history  of  a  dozen  members  of  their  preceding  generation. 
We  believe,  as  a  result  of  our  study  of  cancer,  that  family  histories  taken 
in  a  correct  manner  will  show  that  heredity  may  be  an  important  factor, 
and  that  cancer  occurs  very  frequently  in  some  families,  less  frequently  in 
others,  and  most  rarely  in  the  remainder,  just  as  appendicitis  does. 

Tysser  states  that  heredity  plays  a  part .  in  the  general  incidence  of 
cancer  in  regard  to  species.  Mammary  tumors  are  comparatively  frequent 
in  mice,  while  they  are  rare  in  cattle.  Cattle,  however,  frequently  develop 
primary  tumors  of  the  liver  and  adrenals.  He  emphasizes  the  fact  that 
statistical  inquiries  concerning  the  inheritance  of  a  predisposition  to  cancer 


CARCINOMA  OF  THE  UTERUS  181 

in  man  lack  accuracy,  yet  for  the  most  part  fail  to  indicate  a  tendency. 
He  admits  that  cancer  families  are  noticeably  frequent,  but  states  that  many 
believe  that  they  occur  quite  in  accord  with  the  laws  of  chance.  He  calls 
attention,  however,  to  the  fact  that  melanosarcoma  in  the  gray  horse,  and 
von  Recklinghausen's  disease  appear  to  have  heredity  as  predisposing  causes. 

The  presence  of  cancer  families  in  mice  has  been  absolutely  proved  by 
the  work  of  Maud  Slye.  There  are  numerous  instances  of  cancer  families 
in  the  human  species.  Sir  James  Paget  mentions  a  family  which  suffered 
from  carcinoma  for  three  generations.  Roger  Williams  cites  a  case  of 
uterine  carcinoma  whose  maternal  grandmother,  mother's  sister,  and  two 
sisters  all  died  of  uterine  carcinoma.  Athill  saw  a  carcinoma  in  a  woman 
of  twenty-eight,  whose  mother  and  two  sisters  also  had  carcinoma 
of  the  uterus.  Guthmann  saw  a  cancer  of  the  body  of  the  uterus 
in  three  sisters.  Cullen  reported  3  cases  that  were  observed  in  sisters  whose 
father  died  from  cancer  of  the  face.  One  of  us  (Lynch)  saw  a  cancer  of 
the  corpus  uteri  in  a  patient  whose  sister  died  of  carcinoma  of  the  breast, 
a  brother  from  cancer  of  the  prostate,  and  the  mother  died  from  cancer 
of  the  uterus.  We  have,  moreover,  seen  several  instances  of  cancers  in 
sisters,  and  2  cases  where  the  individual  presented  at  the  same  time  cancer 
of  the  cervix  and  cancer  of  the  breast. 

The  percentage  of  frequency  of  the  family  history  in  uterine  cancer 
series  is  given  by  the  following  authorities: 

Gusserow 7.6  per  cent  in  1,028  cases 

Schroeder 8.2  per  cent        Schroeder,  Barker  and  Sibley  series 

Picot 13      per  cent 

Williams 19.7  per  cent 

Cullen i  g      per  cent  in  176  cases 

Levin 8      per  cent  in     49  cases. 

The  extent  to  which  the  family  history  was  developed  is  not  stated  by  any 
of  the  authors  cited  above. 

Carcinoma  is  supposed  to  occur  more  frequently  among  the  poor  and 
ill-nourished  members  of  society.  Schroeder  has  supported  this  theory  by 
statistics  showing  the  relative  frequency  of  fibroids  and  carcinoma.  In  his 
clinic,  which  is  limited  to  the  poorer  class  of  people,  fibroids  were  noted 
in  the  proportion  of  100  to  61  cancers;  in  the  wealthier  class  of  cases,  the 
proportion  was  changed  from  100  to  332.  These  figures  have  been  adduced 
to  prove  that  the  diminished  resistance  and  impairment  of  vital  growth 
favors  the  development  of  cancer.  Yet  the  influence  of  habit  and  occupation 
is  still  a  matter  of  uncertainty,  and  it  has  not  been  proved  that  carcinoma  of 
the  uterus  is  more  common  among  the  very  poor  than  among  the  wealthy 
class.  Roger  Williams,  among  others,  denies  it  and  argues  that  his  sta- 
tistics show  that  it  is  more  frequent  among  the  rich.  Older  authors  have 
stated  that  the  disease  is  more  frequent  among  those  who  eat  meat  than 


1 82  PELVIC  NEOPLASMS 

in  the  strict  vegetarians.  We  must  remember,  however,  that  the  great 
majority  of  people  are  meat-eaters.  The  statement  receives  no  confirmation 
in  statistics  of  cancer  in  India,  where  the  disease  occurs  in  practically  the 
same  proportion  in  meat-eaters  and  in  those  whose  religion  prohibits  the 
eating  of  any  flesh.  Self-indulgence  in  eating  and  drinking  is  more  likely 
to  be  a  factor  which  favors  an  increase  in  cancer  mortality.  Disturbances 
in  metabolism  from  similar  causes  undoubtedly  cause  arterial  degenerations. 

Cancer  is  usually  stated  to  occur  more  frequently  in  the  colored  than 
in  the  white  races.  Statistics  from  the  Johns  Hopkins  Hospital  confirm 
this  opinion.  The  older  idea  that  the  disease  was  more  common  in  tem- 
perate climates  than  in  the  tropics,  and  among  the  civilized  races  than 
among  the  uncivilized  has  been  disproved  by  many  observations  in  the 
Philippines.  Dudley,  in  1908,  reported  that  carcinoma  of  the  cervix  is  seen 
very  frequently  in  Manila,  where  it  is  more  common  than  any  other  type 
of  cancer,  and  that  the  former  impression  that  cancer  in  the  tropics  is  very 
rare  is  not  borne  out  by  the  facts. 

Green  found  a  definite  relationship  between  the  death  rate  of  carcinoma 
and  the  type  of  fuel  that  was  used  for  hpusehold  purposes,  and  suggests 
that  there  may  be  some  relation  between  coal  and  its  products  of  combus- 
tion and  malignant  disease.  He  states  that  the  death  rate  from  cancer  is 
high  in  northern  France  where  coal  is  consumed  almost  entirely,  whereas 
the  death  rate  is  low  in  southern  France  where  wood  is  used  largely  for 
fuel.  He  believes  that  the  cancer  mortality  varies  almost  in  direct  propor- 
tion to  the  type  of  fuel  consumed. 

There  is  considerable  difference  of  opinion  concerning  local  conditions 
which  have  been  emphasized  in  the  past  as  predisposing  causes  in  the  absence 
of  true  etiological  factors  of  cancer.  Cervical  lacerations  and  erosions  and 
other  effects  of  child-bearing,  and  chronic  inflammatory  conditions  of  the 
uterus,  are  mentioned  among  these;  yet  they  may  be  grouped  under  the 
general  heading  of  chronic  trauma.  Great  emphasis  has  been  laid  upon 
the  relation  between  cervical  lacerations  and  erosions  and  the  development 
of  carcinoma,  although  unfortunately  there  are  no  available  statistics  bear- 
ing upon  this  point.  The  importance  of  cervical  lacerations  has  been  men- 
tioned by  Ruge,  Veit,  Breiski,  and  many  others.  Theilhaber  states  that  the 
anemia  about  the  contracting  scar  favors  the  production  of  cervical  cancer, 
just  as  it  is  supposed  that  the  anemia  following  the  menopause  favors  the 
formation  of  cancer  in  the  body  of  the  uterus.  Williams  states  that  he 
never  found  the  disease  in  a  tear  in  any  of  his  cases,  and  feels  that  there  is 
no  evidence  that  lacerations  play  any  part  in  the  origin  of  cancer.  Boldt, 
on  the  contrary,  has  found  such  a  case,  and  there  are  similar  instances, 
although  they  are  few,  which  have  been  reported  in  the  literature.  Beck- 
man  observed  a  cancer  develop  in  a  cervical  erosion  in  a  case  which  he  had 
treated  over  a  period  of  five  years.  Such  cases,  however,  are  not  necessary 
to  emphasize  the  importance  of  cervical  lacerations,  since  the  secondary 
changes  following  a  cervical  tear  may  well  suffice  as  an  etiologic  factor. 


CARCINOMA   OF   THE   UTERUS  183 

We  have  long  believed  that,  if  all  the  women  who  have  had  children,  were 
to  have  their  cervices  removed  before  the  age  of  forty,  that  cervical  cancer 
would  be  a  comparative  rarity.  The  point  does  not  seem  invalidated  by 
the  actual  fact  that  early  cancers  have  been  found  in  the  scar  of  cervica^' 
repairs  in  several  instances.  The  chronic  endocervicitis  is  undoubtedly  of 
greater  importance  in  the  etiology  than  are  the  lacerations.  Polese  found 
that  34  of  his  48  cancers  had  had  a  chronic  endocervicitis  antedating  the 
tumor.  In  the  absence  of  definite  information  concerning  the  etiology,  it 
seems  fair  to  emphasize  again  the  importance  of  cervical  injuries  and  in- 
flammations. Routine  examinations  of  chronic  endocervicitis  very  often 
show  abnormalities  in  the  cell  morphology  and  histology  which  may  con- 
stitute precancerous  lesions.  We  have  no  definite  knowledge  concerning 
the  part  played  by  previous  inflammation  as  predisposing  causes  for  cancer 
of  the  uterine  body.  Cullen  was  not  able  to  find  that  an  endometritis  ante- 
dated the  growth  in  any  of  the  16  cases  with  this  type  of  cancer.  Genital 
tuberculosis  has  been  observed  in  association  with  carcinoma  of  the  uterine 
body  in  many  instances,  as  is  shown  by  Coblents,  yet,  as  Cullen  suggests,  this 
relation  may  well  have  been  accidental.  Carcinoma  of  the  uterine  body  is 
frequently  associated  with  fibroids.  Olshausen  states  that  10  per  cent  of 
fibroids  occur  with  carcinoma.  Taussig  found  a  similar  percentage  in  his 
recent  review.  There  were  10  cancers  of  the  uterine  body  occurring  in  40 
uterine  fibroids  in  the  Mayo  Clinic.  Levin  was  unable  to  confirm  this  idea 
in  the  analysis  of  his  613  collected  cases,  since  fibroids  were  found  in  the 
uterus  in  5  per  cent  of  the  cervical  cancers  and  in  but  1.5  per  cent  of  the 
fundal  cancers. 

The  great  majority  of  cases  occur  in  women  who  have  borne  children, 
yet  occasionally  carcinoma  occurs  in  virgins,  usually  in  those,  however,  who 
have  had  some  pelvic  condition  which  had  been  treated  with  a  dilatation 
of  the  cervix.  Sampson  found  that  in  412  uterine  carcinoma  only  3  per 
cent  were  nullipara.  Williams,  in  334  cases,  found  that  only  4  per  cent 
were  nullipara.  Cullen,  in  50  cases  of  squamous-cell  carcinoma  of  the 
cervix,  found  that  only  5  had  not  borne  children;  in  14  cases  of  adeno- 
carcinoma  of  the  cervix,  there  were  2  nullipara;  in  19  cases  of  adenocar- 
cinoma  in  the  body  of  the  uterus,  52  per  cent  had  not  borne  children  and  6 
of  the  17  married  women  had  never  been  pregnant. 

Age. — The  great  majority  of  the  cases  of  uterine  cancer  develop 
about  the  time  of  the  menopause.  More  are  noted  in  the  fifth  decade 
than  in  any  other  ten-year  interval.  Cervical  cancer  is  generally  con- 
sidered to  develop  earlier  than  that  in  the  body  of  the  uterus.  Yet  Levin, 
in  his  1,613  collected  cases,  does  not  find  any  difference  in  the  average 
age  of  the  cancers  of  the  uterine  cervix  and  of  the  body.  However, 
Wertheim  has  noted  a  large  proportion  of  his  cases  of  cervical  cancer 
at  an  age  much  earlier  than  that  usually  noted  for  cancers  of  the  uterine 
fundus.  In  his  series  of  500  cases,  there  were  6  per  cent  in  women 


184  PELVIC   NEOPLASMS 

under  30,  and  30  per  cent  in  women  under  40,  and  55  per  cent  in  women 
45  years  and  younger. 

Williams,  in  100  cases,  noted  uterine  cancer  as  follows: 

Before  the  menopause 50  cases 

At  time  of  menopause 21   cases 

Past  the  menopause 29  cases 

Gussefow,  in  3,471  cases,  found  the  following  distribution: 

Years.                        Cases.  Years.                                         Cases. 

17        i  40-5°  1196 

19        i  50-60  856 

20-30 114  60-70  340 

30-40 770  70         and  over 193 

Roger  Williams,  analyzing  500  cases,  showed  the  following  percentages  : 

Years.  Per  cent.  Years.  Per  cent. 

20-25 2  50-55  13 

25-30 7  55-6o  9 

3°-35 ii  60-65  5 

35-40 20  65-70  i 

40-45 17  70         and  over 8 

45-5° •-    16 

A  few  isolated  cases  of  cancer  of  the  uterus  have  been  reported  in  early 
life.  Adams,  in  1916,  records  a  glandular  carcinoma  of  the  cervix  and 
uterus  in  a  child  two  and  a  half  years  old.  Rosenstern  found  a  case 
which  he  describes  as  carcinosarcoma  of  the  cervix  in  a  child  of  three. 
Glockner  reports  a  cervical  cancer  in  a  child  of  seven.  Engelhorn  has 
collected  several  cases  in  very  young  subjects.  Stacey  observed  a  case 
of  adenocarcinoma  of  the  body  of  the  uterus  in  a  girl  of  sixteen.  These 
are  exceptions  to  the  general  rule,  and  there  is  a  possibility  that  in 
other  cases  not  cited  in  this  chapter,  the  disease  is  really  sarcoma.  A 
case  reported  by  Ganghofner  was  described  as  papillomatous  and  there 
is  the  possibility  that  it  was  not  malignant.  Green-Armytage,  writing 
from  India  in  1913,  states  that  he  sees  many  cases  of  inoperable  car- 
cinoma in  very  young  women.  Of  9  cases  which  he  treated  by  ligating 
the  iliac  arteries  5  were  under  thirty,  and  i  was  only  twenty  years 
of  age. 


CARCINOMA   OF   THE   UTERUS  185 


CLASSIFICATION  OF  UTERINE  CANCER 

Much  of  the  older  study  of  uterine  cancer  is  not  of  value  for  inves- 
tigations at  the  present  time,  since  in  a  single  report  there  is  often 
embodied  a  mass  of  statistics  of  both  fundal  and  cervical  cancers  which 
are  grouped  together  as  if  they  were  a  single  entity.  This  confusion, 
unfortunately,  is  maintained  by  a  number  of  writers  of  the  present 
day,  who  also  discuss  *the  various  cancers  of  the  uterus  under  this 
single  heading  without  effort  properly  to  subdivide  them.  Since  can- 
cers of  identical  histology  and  morphology  may  vary  greatly  in  their 
clinical  course,  even  though  they  arise  from  identical  anatomical  struc- 
tures and  location,  it  seems  rational  to  believe  that  we  will  make  slow 
progress  in  the  elucidation  of  this  confusing  question  unless  we  find  a 
way  of  grouping  similar  cases.  This,  of  course,  means  a  very  detailed 
classification.  The  chief  objection  to  detailed  classification  thus  far 
has  been  the  fact  that  we  cannot  determine  the  proper  classification 
for  the  majority  of  late  growths.  This  objection  is  but  theoretical, 
however,  since  our  chief  interest  naturally  must  be  the  study  of  early 
cases,  which  at  the  present  time  are  the  only  ones  that  permit  the 
chance  of  cure.  Fortunately,  they  allow  much  detail  in  their  classifi- 
cation. 

Carcinoma  of  the  uterus  may  be  primary  or  secondary.  Following 
the  rule  that  organs  which  are  often  affected  with  cancerous  changes 
seldom  contain  secondary  growths,  we  find  that  secondary  cancer  of 
the  uterus  is  very  rare.  In  1908,  Offergeld  was  able  to  collect  but  22 
cases  after  a  very  extensive  review  of  the  literature.  The  cases  in  his 
series  developed  secondarily  from  tumors  which  were  primary  in  the 
stomach,  breasts,  and  rectum.  The  tumors  in  his  series  which  were 
found  both  in  the  myometrium  and  mucosa,  had  resulted  from  exten- 
sion by  way  of  the  lymphatics,  and  had,  in  several  instances,  given  off 
metastases  from  their  uterine  growths.  This  finding  is  somewhat  at 
variance  with  that  of  Williams,  who  stated  that  the  secondary  uterine 
cancers  were  most  often  found  immediately  beneath  the  peritoneum 
of  the  uterine  body.  Both  Williams  and  Offergeld  agreed  that  meta- 
stases were  usually  multiple. 

A  number  of  classifications  have  been  proposed  for  the  arrange- 
ment of  cancers  of  the  uterus.  They  may  be  grouped  from  different 
standpoints,  thus:  (i)  according  to  the  site  of  the  original  growth; 
(2)  according  to  the  histology  of  the  tumor;  (3)  according  to  the 
morphology  presented  by  the  cancer. 

According  to  Topography. — Cancers  may  be  divided  according  as 
they  originate  in  the  cervix  or  in  the  body  of  the  uterus.  In  the  same 
manner  we  may  divide  the  cervical  cancers  according  as  they  develop  in 
the  vaginal  portion  of  the  cervix,  or  in  the  cervical  canal. 


186  PELVIC   NEOPLASMS 

According  to  Histology. — There  are  two  main  divisions  from  the 
clinical  and  histological  side:  (i)  the  squamous  cell  carcinoma  of  the 
cervix;  (2)  the  glandular  carcinoma  of  the  body  of  the  uterus.  This 
classification  is  the  common  one  and  has  been  used  for  many  years. 
It  has  not  obtained  universal  acceptance,  however.  Many,  as  Schott- 
laender,  have  claimed  that  any  genetic  classification  is  impossible,  since 
both  the  cylindrical  cell  and  squamous  cell  tumors  can  arise  both  from 
the  cylindrical  surface  epithelium  of  the  cervical  canal,  or  from  the 
squamous  cell  epithelium  of  the  portio.  Schoftlaender  further  states 
that  the  additional  term,  round-cell  tumor,  has  been  introduced  because 
of  the  limitations  in  this  classification  and  urges  the  return  to  the  rudi- 
mentary classification  of  uterine  cancers  into  (i)  solid  growths;  (2) 
primary  glandular  cancers;  and  (3)  both  the  solid  and  the  primary 
glandular  cancers  in  combination.  He  takes  into  account  the  condition 
of  the  epithelial  nests.  Solid  carcinoma  do  not  have  structures  which 
suggest  glands.  They  come  from  preexisting  squamous  epithelium  aris- 
ing from  the  metaplastic  cylindrical  surface  epithelium  in  the  portio, 
and  from  the  epithelial  surfaces  and  the  epithelium  of  the  glands  in 
the  cervix,  and  the  endometrium  of  the  uterus.  Solid  carcinoma  are 
divided  further  into  ripe,  unripe  and  midripe  forms.  The  ripe  type 
shows  distinct  prickle  cells  in  individual  cell  nests,  which  feature  is 
lacking  in  the  unripe  and  midripe  forms,  irrespective  of  the  presence 
of  hornification.  The  midripe  and  unripe  forms  are  differentiated 
according  to  the  type  of  cell  which  is  present  in  the  growth.  The 
unripe  type  contains  small,  round,  irregular  cells,  in  centra-distinction 
to  the  cells  of  the  midripe  tumors  which  are  polygonal. 

The  objection  raised  by  Schottlaender  does  not  seem  valid  to  us. 
It  should  be  our  aim  to  classify  similar  cancers  so  that  we  may  learn 
the  clinical  and  histological  features  of  each  of  the  various  subgroups. 
Men  working  with  cancer  know  that  there  are  several  different  va- 
rieties of  squamous  cell  carcinoma  of  the  portio  vaginalis,  which 
vary  in  their  habits  of  growth,  although  all  of  them  may  present 
identical  features  of  morphology  and  histology.  Advance  will  not 
result  from  simplification  of  classifications.  We  should  carry  our  sub- 
divisions down  until  there  are  only  identical  types  of  cancers  in  a  single 
group.  While  this  is  not  fully  possible  in  any  classification  which 
has  been  advanced  at  present,  the  main  classifications  of  topography, 
morphology  and  histology  are  proving  extremely  useful. 

According  to  Morphology. — Cancer  of  the  uterus  may  also  be 
divided  according  to  the  morphologic  features  of  the  growth,  irrespec- 
tive of  the  situation  or  of  its  histologic  structure.  One  definite  type  of 
tumor  tends  to  evert  as  it  grows,  giving  rise  to  a  papillary,  cauliflower- 
like  mass.  It  stands  to  reason  that  this  group  will  give  symptoms  fairly 
early,  because  the  papillary  masses  are  exposed  to  trauma  which 
readily  causes  bleeding.  The  other  group  of  cancers  presents  the  same 


CARCINOMA   OF   THE    UTERUS 


187 


histologic  picture,  but  inverts  as  it  grows  and  forms  a  nodular  mass  of 
cancerous  tissue  which  tends  to  infiltrate  the  neighboring  structures. 
It  is  readily  apparent  that  this  type  of  cancer  may  not  give  symptoms 
until  ulceration  occurs  and  a  secondary  hemorrhage  results.  The  division 
into  everting  and  inverting  forms  is  not  always  frank,  and  occasionally  both 
types  may  be  present  in  the  same  specimen.  Some  cases  show  tran- 
sition from  one  morphologic  form  to  the  other  in  the  process  of  growth. 
Fortunately,  however,  the  majority  of  early  tumors  permit  this  essen- 
tial morphologic  classification.  Various  synonyms  for  the  everting 
form  have  been  used,  namely,  everting,  vegetating,  papillary,  and  cauli- 
flower. The  inverting  type  is  synonymous  with  contracting,  infiltrat- 
ing, nodular,  ulcerating  and  parenchymatous.  Either  form  may  be 
further  subdivided  according  to  the  nature  of  the  predominating  cell. 
When  the  tumor  is  soft,  necrotic,  or  sloughing,  it  may  be  called  medul- 
lary cancer.  When  the  stroma  predominates,  the  tumor  is  often  called 
a  scirrhous  cancer. 

Combining  the  above  classifications,  we  shall  consider  the  subject 
under  the  following  heads:  squamous  cell  cancer,  and  adenocarcinoma. 
Each  form  is  subdivided  according  to  its  anatomical  position,  and  fur- 
ther divided  according  to  the  morphologic  features  of  growth. 

A     f^t  j.1         ^L-          •     1-        f  everting 
A.  Of  the  portio  vagmahs     {  inverti  °g 


Squamous   cell 
carcinoma 


Adenocarcinoma 


B.  Of  the  cervical  canal 


C.  Of  the  uterine  body 

A.  Of  the  cervical  canal,  arising 

from 

B.  Of  the  uterine  body,  arising 

from 


e  -xi.  r          (  everting 

surface  epithelium   (  inverti  * 


cervical  glands 

t  -j.1.  r         f  everting 

surface  epithelium    |  inverti  *g 

endometrial  glands  { 


SQUAMOUS  CELL  CARCINOMA  OF  THE  UTERUS 

Squamous  cell  carcinoma  develops  usually  on  the  vaginal  portion 
of  the  cervix,  although  it  may  arise  in  the  cervical  canal,  or  possibly 
even  in  the  cavity  of  the  uterus.  It  is  the  most  common  form  of  uterine 
cancer.  Cullen  found  that  123  of  his  141  cases  of  cervical  carcinoma 
were  of  this  type,  and  similar  proportions  are  found  in  the  larger  clinics 
of  America.  Statistics  from  abroad  give  a  somewhat  different  proper- 


1 88 


PELVIC  NEOPLASMS 


tion.  There  were  236  squamous  cell  cancers  arising  from  the  portio  in 
422  cervical  cancers  in  Hofmeier's  statistics.  Baecker  found  that  282 
of  a  series  of  379  cervical  cancers  were  also  of  the  same  type. 

Squamous    Cell    Carcinoma    of    the    Portio    Vaginalis — EVERTING 
TYPE. — This  form  of  cancer  develops  usually  on  the  vaginal  portion  of  the 


FIG.  58. — EVERTING  SQUAMOUS-CELL  CARCINOMA  OF  CERVIX  WITH  CANCEROUS  POLYP. 

cervix,  external  to  the  external  os,  and  begins  as  a  proliferation  of  epithe- 
lium which  soon  invades  the  underlying  tissues  (Fig.  58).  Early  stages 
are  seldom  seen,  since  they  occasion  no  symptoms,  yet  they  have  been  de- 
scribed by  Waldeyer,  Ruge,  Veit,  Cullen,  Stone,  and  others.  The  very  small 
tumor  may  appear  as  a  diffuse,  low,  papillary  outgrowth  on  the  vaginal 
mucosa  which  bleeds  fairly  easily.  The  tissues  immediately  surrounding  the 


CARCINOMA    OF    THE    UTERUS  189 

growth  are  slightly  swollen.  On  section,  there  are  a  number  of  small  papillae 
presenting  a  yellowish  white  and  somewhat  translucent  appearance.  With 
the  progress  of  the  disease,  the  tumor  increases  in  size,  covers  the  cervix  with 
a  cauliflower  mass  which  may  be  sessile,  or  have  a  broad  pedicle.  The  cervix 
becomes  irregular  and  tabulated  on  the  areas  not  covered  by  the  growth. 
Superficial  extensions  occur  in  the  cervix  and  in  the  upper  part  of  the 
vaginal  canal.  Isolated  nodules  are  occasionally  found  in  the  vaginal  wall 
at  some  distance  from  the  main  tumors.  The  whole  upper  vagina  may  be 
distended  with  a  large  fungating  mass.  Ulceration  comes  on  early  and  is 
followed  by  a  slough  which  leaves  wide  excavations  in  the  tumor  proper, 
the  cervix,  or  the  vagina.  The  cervix  is  often  completely  destroyed,  and 
rarely  the  growth  may  perforate  into  the  bladder  or  rectum.  It  will  be 
seen  that  this  type  of  growth  is  very  likely  to  give  symptoms  early.  Leu- 
korrhea  is  the  initial  symptom,  and  soon  becomes  discolored  with  blood, 
and  later  may  be  obscured  by  frank  hemorrhage.  In  the  early  stages,  the 
cancer  is  purely  local,  and  since  it  expends  the  greater  part  of  its  energy 
in  growing  into  the  cavity  of  the  vagina,  it  is  not  malignant  in  the  sense 
that  the  inverting  growth  is.  When  the  projecting  polyp  encounters  re- 
sistance, it  is  stimulated  to  greater  activity,  and  the  tumor  now  grows  back 
into  the  surrounding  tissues.  Unfortunately,  the  frankly  polypoid  tumors 
constitute  a  small  per  cent  of  the  squamous  epitheliomata  of  the  vaginal 
portion  of  the  cervix,  and  probably  occur  once  for  every  10  or  1 1  inverting 
cancers  in  the  same  region. 

Microscopic  Appearance. — In  the  earliest  stages  there  is  proliferation 
of  the  deepest  cells  of  the  surface  epithelium  which  forms  irregular 
branching  columns  and  extends  into  the  basement  tissues.  There  is  a 
cellular  infiltration  in  the  connective  tissue  which  results  coincidently 
with  or  even  precedes  the  epithelial  invasion.  There  are  different  views 
concerning  its  interpretation.  Ribbert  claims  that  the  cellular  infiltra- 
tion is  the  primary  process  and  indicates  some  inflammatory  condition, 
since  it  cannot  arise  from  the  epithelial  proliferation  alone.  He  found, 
in  skin  carcinoma,  in  the  very  earliest  stages,  a  scab  composed  of  horny 
cells  and  the  secretion  of  sebaceous  glands  which  he  believes  acted  as 
irritant,  from  which  he  concludes  that  carcinoma  originates  as  the 
result  of  subepithelial  inflammation  caused  by  epithelial  products  which 
diminish  the  differentiation  of  the  epithelium  and  liberate  the  prolifer- 
ated growth.  Early  stages  of  carcinoma  of  the  cervix  are  rarely  seen 
because  the  tumors  may  present  no  symptoms,  and  may  be  recognized 
only  during  examinations  conducted  for  other  reasons.  The  most  com- 
mon type  is  composed  of  pavement  epithelium  devoid  of  alveoli,  and 
presents  pearls,  prickle  cells,  and  hornification.  True  acanthomata  are 
occasionally  encountered.  There  is  the  typical  hypertrophy  of  the 
squamous  epithelium  which  presents  elongated  papillae  which  dip 
down  into  the  underlying  structures.  The  papillae,  on  transverse  sec- 
tion, are  round,  oval,  or  irregular.  Papillary  outgrowths  now  appear 


I9o  PELVIC   NEOPLASMS 

on  the  surface  of  the  cervical  epithelium.  The  projections  of  epithe- 
lium are  soon  provided  with  a  delicate  stem  of  vascularized  stroma 
that  extends  up  into  the  epithelial  mass.  The  well-developed  growth 
is  comprised  of  cells  arranged  in  columns  of  various  dimensions.  The 
cells  are  rounded,  or  polyhedral,  or  irregularly  shaped,  and  occasionally 
there  are  giant  ones.  Usually  the  epithelial  cells  conform  rather  closely 
to  the  type  of  the  parent  cell,  while  at  other  times  they  deviate  con- 
siderably even  in  early  growths.  Epithelial  pearls  occur,  yet  they  are 
not  nearly  as  frequent  as  in  the  epithelial  tumors  which  develop  in  the 
skin,  because  of  the  scanty  development  of  the  stratum  cornium  in 
the  cervical  mucosa.  The  epithelium  surrounding  the  growth  appears 
normal,  even  as  far  as  the  very  edge  of  the  tumor,  except  for  a  round- 
cell,  infiltration  which  surrounds  the  growth.  At  the  margins  of  the 
growth,  the  interpapillary  processes  are  lengthened,  and  occasionally 
appear  as  long,  slender,  anastomosing  cords.  A  zone  of  round  cells 
surrounds  the  epithelial  downgrowths.  Eosinophils  are  occasionally 
seen.  Degenerations  are  frequent  in  the  older  portions  of  the  tumor 
and  follow  disturbance  of  the  blood  supply.  There  are  cell  inclusions 
of  leukocytes,  hyaline  droplets,  and  even  other  epithelial  cells.  The 
principal  degenerations  are  coagulation  necrosis,  fatty  and  hyaline 
changes,  vacuolization  and  nuclear  fragmentation. 

INVERTING  TYPE. — This  type  also  begins  as  a  proliferation  of  the  epi- 
thelium of  the  vaginal  portion  of  the  cervix,  but  the  papillary  forma- 
tion is  absent  or  is  evidenced  to  a  comparatively  slight  degree.  The 
tumor  early  inverts  into  the  underlying  connective  tissues.  The  earlier 
stages  may  present  as  a  hard  nodule  in  the  substance  of  the  cervix. 
The  lip  of  the  cervix  surrounding  the  growth  is  usually  hypertrophied, 
appears  livid  and  glazed,  and  is  firm  and  infiltrated  to  the  touch.  There 
may  be  no  other  evidence  of  the  tumor,  since  it  develops  in  the  connec- 
tive tissue  beneath  the  cervical  epithelium.  The  growth  occasions  no 
symptoms  at  this  time,  and  may  escape  recognition  on  casual  inspec- 
tion. As  the  disease  progresses,  there  is  likely  to  be  necrosis  in  the 
central  portion  with  a  consequent  production  of  a  deep,  ragged  ulcer 
of  typical  carcinomatous  appearance.  Occasionally  the  tumor  grows  back 
into  the  cervix  and  may  nearly  surround  the  cervical  cavity.  Before 
necrosis  occurs,  the  surface  epithelium  surmounting  the  growth  may 
be  thickened  and  puckered,  suggesting  the  retraction  so  often  seen  in 
cancers  of  the  breast.  We  have  seen  the  entire  cervical  stump  in  this 
type  of  tumor  washed  off  in  the  preliminary  preparation  for  operation. 
In  these  cases,  there  must  have  been  central  necrosis  in  the  tumor 
which  had  not  extended  to  the  surface.  As  the  disease  progresses,  it 
invades  the  deeper  tissues  of  the  cervix,  and  extends  directly  outward 
into  the  paracervical  tissues.  Unfortunately,  this  inverting  type  of 
cervical  cancer  is  far  more  common  than  the  preceding,  more  malig- 
nant, and  much  more  difficult  to  diagnose  in  the  early  stages.  It  may 


CARCINOMA  OF   THE   UTERUS  191 

present  on  the  surface  only  a  small,  hard  nodule,  yet  may  have  already 
invaded  deeply  the  adjacent  tissue.  Occasionally  the  cancer  may  pre- 
sent as  large  nodular  masses,  when  it  is  described  as  nodular  cancer. 
As  a  rule,  the  process  of  invasion,  necrosis  and  ulceration  goes  on 
together,  when  it  is  described  as  an  ulcerative  cancer.  Clinical  symp- 
toms do  not  usually  occur  until  the  stage  of  necrosis  and  ulceration, 
and  consist  of  bleeding  and  a  serous  vaginal  discharge.  It  will  be  seen, 
therefore,  that  a  cancer  which  undergoes  necrosis  at  an  early  period 
gives  symptoms  sooner  than  one  in  which  this  process  is  delayed. 

Microscopically  the  picture  resembles  that  in  the  everting  type  of  the 
squamotts  cell  carcinoma  of  the  portio  vaginalis.  Solid  cell  cords  and  cell 
nests  are  common.  There  is  marked  reaction  of  the  connective  tissues  as 
a  consequence  of  the  ulceration.  Changes  in  the  endometrium  are  often 
found  in  association  with  the  cervical  carcinomata,  varying  from  a  glandular 
and  interstitial  hypertrophy  with  dilated  glands,  to  an  overgrowth  of  epithe- 
lium and  cell  reactions  in  the  stroma.  There  may  be  an  increase  in  the 
spindle  cells  and  there  is  usually  a  round-cell  infiltration  (Abel  and  Lan- 
dau). Krause  has  described  the  transformation  of  the  cylindrical  epithe- 
lium into  a  type  resembling  the  squamous  variety  containing  both  flat  and 
polyhedral  cells. 

COMBINING  EVERTING  AND  INVERTING  TYPES. — The  combination  of 
both  everting  and  inverting  types  may  exist,  and  the  disease  may  begin 
as  an  inverting  neoplasm  which  finally  breaks  through  its  shell  and 
assumes  the  everting  form.  More  commonly,  the  growth  begins  in 
the  everting  manner,  but,  encountering  resistance  which  stimulates  the 
cell  proliferation,  it  begins  to  infiltrate.  Papillary  outgrowths  may 
spring  from  the  floor  of  an  ulcer  in  an  inverting  growth.  These  varia- 
tions do  not  impair  the  classification  since,  in  combined  forms,  the 
growth  must  be  classed  according  to  the  prevailing  type. 

Squamous  Cell  Carcinoma  of  the  Cervical  Canal. — This  form  of 
cancer  is  known  to  arise  in  the  cervix,  when  the  point  of  transition  of 
the  squamous  cell  epithelium  into  the  columnar  type  occurs  above  the 
external  os.  It  is  a  question  whether  it  may  develop  from  cylindrical 
epithelium  which  has  undergone  metaplasia  and  has  been  transformed 
into  epithelial  masses  which  resemble  the  squamous  type.  There  may 
be  everting  and  inverting  forms. 

The  everting  form  in  its  development  may  come  to  fill  the  cervical 
canal  and,  encountering  resistance,  may  grow  downward  and  protrude 
through  the  external  os  as  a  polypoid  growth.  Extensions  occur  to 
the  lateral  margins  and  the  tumor  may  extend  over  the  vaginal  por- 
tion and  be  indistinguishable  from  the  type  which  arises  primarily 
there  (Fig.  60).  If  the  mass  occludes  the  cervical  canal,  pyometra 
results. 

The  inverting  type  which  develops  in  the  cervical  canal  occurs  in 
the  same  manner  already  described  for  growths  involving  the  vaginal 


1 92  PELVIC  NEOPLASMS 

cervix.  The  cancer  which  arises  within  the  canal  first  attacks  the 
surrounding  mucosa,  and  extends  out  on  all  sides  into  the  cervical 
tissues.  Infiltration  and  ulceration  finally  result,  and  the  cervix  sloughs 
away.  There  results  only  a  thin  shell  surrounding  the  carcinomatous 
ulcer,  which  cannot  be  distinguished  from  later  stages  of  the  inverting 
type  of  epithelioma  of  the  vaginal  portion  of  the  cervix.  Very  rarely 
necrosis  may  be  deferred,  and  the  cervix  presents,  on  inspection,  as  a 
thick  cervix  covered  with  hypertrophied  mucosa.  The  disease  rarely 
invades  the  uterine  cavity,  and  when  it  does,  we  are  uncertain  whether 
it  extends  by  direct  invasion  or  is  carried  by  a  metastases  to  the  endo- 
metrium  (see  methods  of  extension,  p.  196). 

The  diagnosis  of  this  type  presents  all  the  difficulties  which  are 
encountered  in  the  inverting  cancers  of  the  portio.  It  is  clear  from  the 
above  description  that  the  diagnosis  of  the  type  may  be  made  only 
in  the  early  growths. 

Squamous  Cell  Carcinoma  of  the  Body  of  the  Uterus. — The  ques- 
tion whether  the  normal  uterine  epithelium  surm.ounting  the  endome- 
trium  may  be  replaced  by  squamous  epithelium  has  long  been  under 
debate.  We  often  find  in  routine  examinations,  usually  in  association 
with  pelvic  inflammatory  conditions,  a  heaping  up  of  cells  in  the  sur- 
face epithelium  which  suggests  the  beginning  of  a  reversion  to  squa- 
mous cell  epithelium.  A  number  of  investigators  have  reported  such 
findings,  notably  Zeller,  von  Rosthorn,  and  Ries.  Its  rarity  was  em- 
phasized by  Ries  who  found  in  routine  examinations  of  200  uterine 
scrapings  only  i  that  had  undergone  this  change.  This  is  not  in 
accord  with  our  experience,  since  we  frequently  observe  it.  The  ques- 
tion assumes  importance  in  connection  with  the  beginning  of  cancer. 
Are  these  changes  in  the  epithelium  purely  the  result  of  inflammation 
or  are  they  indicative  of  precancerous  changes?  The  finding  of  3 
primary  acanthoma  of  the  body  of  the  uterus  (Gebhard,  Kaufmann, 
Flaischlen)  strongly  suggest  the  possibility  that  squamous  cell  carci- 
noma may  arise  as  primary  growths  of  the  uterine  body.  The  oppo- 
nents of  the  view  usually  state  that  they  are  more  likely  to  be  sec- 
ondary extensions  from  primary  tumors  of  the  cervix  or  that  they 
have  arisen  from  metastases.  The  3  tumors  adduced  as  primary,  all 
appeared  in  elderly  women.  Others  have  noted  that  adenocarcinoma 
of  the  uterine  fundus  may  show  so  many  squamous  cells  that  the  tumor 
suggests  a  true  adenoacanthoma.  Some  have  even  shown  pearls;  more 
commonly,  however,  the  squamous  cells  appear  in  foci  of  the  alveolar 
lining,  and  are  clearly  demarcated  from  the  cylindrical  epithelium.  A 
combination  of  squamous  cell  carcinoma  and  adenocarcinoma  of  the 
corpus  have  been  described  by  E.  Kaufmann,  who  holds  that  there 
is  a  double  origin  from  the  surface  epithelium  which  had  been  previ- 
ously changed  to  the  squamous  type  for  one  growth,  and  from  the 
glands  of  the  endometrium  for  the  other. 


CARCINOMA   OF   THE   UTERUS  193 


ADENOCARCINOMA  OF  THE  UTERUS 

Adenocarcinoma  of  the  Cervix. — Adenocarcinoma  which  produce 
atypically  the  alveoli  of  cervical  glands  occur  in  a  small  proportion  of 
cases.  The  new  growths  may  arise  from  the  surface  epithelium  of 
the  cervix  or  from  that  of  the  cervical  glands.  We  cannot  readily 
distinguish  the  frequency  of  the  two  types,  since  a  differentiation  is 
possible  only  in  the  very  early  cases.  The  tumors  may  be  everting  or 
inverting,  although  as  a  class  they  are  distinguished  by  their  power 
to  invade  the  underlying  tissues  at  a  very  early  period.  The  everting 
growth,  which  arises  from  the  surface  epithelium,  first  appears  as  a 
proliferation  of  epithelium  which  soon  presents  a  papillary  structure. 
It  grows  into  the  cervical  canal  and  extends  along  its  course,  although, 
at  the  same  time,  it  deeply  penetrates  the  cervical  tissues.  When  the 
disease  begins  low  down  in  the  cervical  canal,  the  cervical  lips  are  soon 
involved  and  appear  thickened,  infiltrated  and  glazed.  When  it  begins 
higher  up,  they  are  usually  only  hypertrophied  on  inspection,  although 
they  feel  nodular  to  the  examining  finger.  In  a  considerable  number 
of  cases,  a  cauliflower  mass  is  finally  extruded  through  the  external 
os  and  presents  a  worm-eaten  appearance  because  of  the  myriads  of 
small,  fingerlike  polyps  which  spring  from  the  surface.  The  cervix 
itself  rarely  bleeds  from  touch  before  there  is  a  tumor  which  presents 
through  the  os.  The  polyp  masses,  however,  are  friable  and  bleed 
fairly  readily,  although  not  as  easily  as  the  everting  squamous  cell 
epithelioma.  Ulceration  usually  comes  very  late.  The  entire  cervix 
may  be  converted  into  a  carcinomatous  mass  without  noticeable  ne- 
crosis or  large  areas  of  ulceration.  Inspection  of  the  tumor  shows  that 
it  is  composed  of  a  mass  of  branching  papillae,  which  consist  of  a  stalk 
of  connective  tissue  surrounded  by  several  layers  of  epithelium.  The 
carcinoma  on  section  is  firm  and  dense,  and  presents  a  yellowish  white 
color  which  stands  out  in  sharp  contrast  to  the  uterine  muscle.  Glis- 
tening bands  of  stroma  may  be  seen  on  careful  inspection.  The  tumor 
has  an  irregularly  advancing  margin.  Microscopically,  the  growth 
begins  by  proliferation  of  the  surface  epithelium.  The  cells  are  heaped 
in  an  irregular  manner,  and  soon  assume  the  appearance  of  small 
glands,  which  are  close  together  and  are  devoid  of  stroma.  This  pic- 
ture rather  suggests  the  squamous  cell  carcinoma.  The  connective 
tissue  stroma  soon  grows  in  and  branching  papillae  result.  The  stroma 
is  composed  of  spindle  cells  and  is  relatively  thicker  and  less  vascular 
than  that  of  the  everting  squamous  cell  carcinoma.  For  this  reason, 
it  does  not  break  down  as  easily  nor  bleed  as  readily.  The  surface  is 
covered  by  one  or  more  layers  of  epithelium  which  present  many  vari- 
ations in  shape  and  size.  As  a  rule,  the  cells  are  cylindrical  when  there 
is  but  a  single  layer.  They  are  more  likely  to  be  polygonal  when  there 


IQ4 


PELVIC  NEOPLASMS 


are  several  layers.  There  is,  however,  a  wide  range  in  their  form  and 
size.  The  nuclei  are  more  apt  to  be  large,  round  and  vesicular,  but 
vary  in  appearance  and  in  staining  properties,  as  do  the  cells.  Giant 


CaTcinoma    cf  cervix 


osierior  Up   of 
Cervix 


FIG.  59. — OCCLUSION  OF  CERVICAL  CANAL  BY  A  SQUAMOUS-CELL  CARCINOMA  WITH  VAGINAL 

METASTASIS. 

cells  are  often  noted,  and  karyorrhexis  is  frequently  seen.  Round-cell 
infiltration  accompanies  the  growth  and  is  thought  by  some  to  suggest 
the  degree  of  the  malignancy  of  the  tumor;  its  extent  varying  inversely 
with  the  malignancy  of  the  cancer. 


CARCINOMA   OF    THE    UTERUS 


The  inverting  type  of  the  growth  is  more  frequent  and  arises  more 
often  from  the  glands  than  from  the  epithelium  of  the  surface.  It  early 
inverts  and  is  not  likely  to  present  the  characters  of  the  preceding  type 
until  the  very  late  stages.  In  fact,  the  surface  epithelium  may  be 
smooth  or  thinned  out  over  a  deep-seated  nodular  tumor.  These 
growths  early  invade  the  cervical  tissues  growing  out  directly  toward 
the  parametrium.  Consequently,  the  cervical  lips  may  appear  only 
hypertrophied  or  glazed  and  thickened  until  the  very  late  stages.  Pal- 
pation confirms  this  appearance,  although  it  detects  hard  nodular 


FIG.  60. — INVERTING  ADENOCARCINOMA  OF  CERVIX  WITH  EXTENSIVE  INVASION. 

masses.  Very  rarely  does  a  tumor  grow  down  into  the  vagina  or  attain 
a  size  sufficient  to  fill  its  upper  portion.  It  tends  to  grow  directly 
laterally.  Ulcer  formation  usually  occurs  only  late  in  the  disease. 
Leukorrhea  is  the  early  symptom,  since  bleeding  may  not  result  until 
the  advent  of  ulceration.  The  diagnosis  may  be  extremely  difficult. 
Even  after  the  uterus  is  removed,  the  growth  may  not  be  recognized 
until  the  organ  is  opened.  Rarely  a  growth  which  has  originated  in 
the  cervical  glands  breaks  through  into  the  vagina  and  assumes  the 
polypoid  type  on  its  surface.  Microscopically  the  tumor  process  may 
be  best  studied  in  glands.  It  may  begin  in  the  ducts  or  in  the  fundus 


IQ6  PELVIC  NEOPLASMS 

of  one  of  the  cervical  glands.  The  cells  proliferate  at  opposite  sides, 
and  become  arranged  in  a  number  of  small  teats  or  club-shaped 
growths  which  gradually  coalesce  with  their  neighbors  and  form  small 
cancerous  glands.  At  one  end  of  a  normal-sized  gland  there  may  be 
a  mass  of  cancerous  tissue  which  completely  occludes  it,  with  a  struc- 
ture which  appears  to  consist  of  a  dozen  or  more  newly  formed  can- 
cerous glands  with  little  or  no  connective  tissue  binding  their  lumen. 
The  original  gland  shortly  becomes  filled  and  the  cancerous  tissue  then 
invades  the  supporting  structures.  Occasionally,  the  early  processes 
assume  the  characteristics  of  the  squamous  cell  carcinoma,  largely 
because  of  the  scanty  connective  tissue  framework.  In  the  advanced 
forms  the  carcinoma  may  present  as  alveolar,  diffuse  or  scirrhous. 
Occasionally  tumors  are  found  in  which  the  lumina  of  the  alveoli  are 
completely  obliterated,  when  the  tumor  assumes  a  solid  appearance. 
The  entire  cervix  may  be  invaded  by  glands  which,  on  cross  section, 
will  show  small  offshoots  with  dentate  branches  forming  new  cancer- 
ous alveoli.  Sometimes  the  growth  can  be  traced  from  a  normal  gland 
which  has  been  lined  by  a  second  layer  of  epithelium  into  the  can- 
cerous portion,  where  the  cells  are  five  or  six  layers  deep,  varying 
in  appearance  and  in  the  staining  reactions.  Karokinetic  figures  are  not 
uncommon.  The  cells  differ  greatly  from  those  of  the  normal  cervical 
epithelium,  and  cannot  be  recognized  readily  as  their  derivative.  The 
surrounding  connective  tissue  shows  a  round-cell  infiltration  which  is 
usually  more  marked  along  the  advancing  edge.  As  in  the  preceding 
torm,  there  appears  to  be  an  inverse  relation  between  the  extent  of 
the  round-celled  infiltration  and  the  rapidity  of  the  growth.  Degenera- 
tions are  seen  in  the  larger  tumors  and  may  progress  to  necrosis.  The 
stroma  occasionally  presents  a  degeneration  which  resembles  mucoid 
tissue. 

Adenocarcinoma  of  the  Body  of  the  Uterus. — This  type  of  uterine 
cancer  will  be  separately  considered  (see  p.  297). 


CARCINOMA  OF  THE  CERVIX 

Method  of  Extension  of  Cervical  Cancer.— The  disease,  unfor- 
tunately, does  not  tend  to  remain  localized  for  any  time,  but,  at  a  very 
early  stage,  depending  upon  the  degree  of  malignancy,  spreads  to  the 
surrounding  tissues,  either  by  direct  extension,  or  by  means  of 
lymphatic  and  blood  stream  metastases.  By  these  methods  the  cancer 
is  carried  to  adjacent  structures  where  it  develops.  The  disease  may 
extend  in  thick  masses,  or  by  thin  threads  of  cancerous  tissue,  before 
the  condition  is  recognized  clinically  as  cancer. 

The  direct  extension  is  most  marked  in  a  lateral  direction,  and  the 
bases  of  the  broad  ligaments  are  first '  involved.  The  growth 


CARCINOMA  OF  THE  UTERUS  197 

soon  breaks  through  into  the  lymph  tracts,  and  groups  of  small  cells 
are  carried  along  in  the  current  until  they  are  arrested  by  the  con- 
stricted lumen  in  the  lymph  nodes.  From  this  point  they  back  up 
until  the  new  cells  have  gained  volume  sufficient  to  break  out  of  the 
channels. 

The  broad  ligaments  are  indurated  in  late  cancers.  The  majority 
of  authors  lay  much  stress  upon  this  sign  as  an  indication  of  cancerous 
involvement,  yet  thickenings  of  the  parametrium  in  connection  with 
cervical  carcinoma  may  be  nonmalignant  in  character,  and  may  rep- 
resent only  the  absorption  from  the  cancerous  ulcer.  This  favorable 
condition,  however,  is  not  often  seen.  It  is  more  important  to 
bear  in  mind  that  invasion  of  the  parametrium  by  cancer  may 
occur  without  macroscopical  change.  Consequently,  microscopic 
study  is  necessary  to  prove  the  presence  or  absence  of  cancer.  This 
is  well  shown  by  an  early  series  of  Wertheim's  in  which  the  para- 
metrium was  involved  in  60  per  cent,  while  in  another  14  per  cent 
no  cancer  cells  could  be  found  by  microscopical  study,  although  there 
was  considerable  infiltration  of  the  tissue.  On  the  other  hand,  cancer 
was  found  in  22.5  per  cent  of  cases,  although  the  parametrium  was 
soft  and  felt  normal.  The  parametrium  was  found  invaded  by  carci- 
noma in  75  per  cent  of  Schottlaender's  cases.  Unfortunately,  there 
does  not  seem  to  be  a  relation  between  the  size  and  age  of  the  primary 
growth  and  the  involvement  of  the  parametrial  tissues.  Occasionally, 
small  tumors  may  invade  in  a  very  early  period  of  growth,  while  larger 
tumors  may  remain  local  for  a  considerable  length  of  time. 

Carcinoma  of  the  cervix  rarely  extends  into  the  body  of  the  uterus, 
and,  in  the  few  cases  which  do  not  follow  the  rule,  the  growth  is  gener- 
ally confined  to  the  musculature.  Very  exceptionally,  cases  are  seen 
in  which  the  whole  inner  surface  of  the  uterine  cavity  has  been  involved 
by  secondary  extensions.  Involvement  of  the  uterine  body  may  occur 
by  means  of  the  lymphatics,  which  run  in  the  outer  muscular 
wall  of  the  uterus  and  anastomose  with  those  of  the  cervix.  It  is 
found  not  uncommonly  at  a  higher  level  in  the  myometrium  than  it  is 
in  the  endometrium.  The  latter  structure  is  occasionally  invaded 
through  its  deeper  layers  by  extension  from  processes  in  the  muscular 
coat.  At  times  the  whole  uterus  is  so  involved  that  it  is  impossible  to 
determine  the  origin  of  the  neoplasm.  Separate  foci  of  cancer  have 
been  found  in  the  endometrium  at  a  considerable  distance  from 
growths  which  were  primary  in  the  cervical  region  (Jellett,  Cullen). 

The  vagina  may  be  invaded  along  the  surface  by  direct  extension 
(most  common  method),  by  way  of  the  lymphatics  in  its  muscular 
wall,  or  frequently  by  retrograde  lymphatic  metastases.  It  is  involved 
in  nearly  50  per  cent  of  the  operable  cases,  and  is  more  apt  to  be 
invaded  when  the  cancer  begins  on  the  vaginal  portion  of  the  cervix. 
In  the  everting  type  of  growth,  the  metastases  are  usually  very  super- 


i  g8  PELVIC  NEOPLASMS 

ficial  and  spread  by  surface  contact,  although  they  are  not  well  marked 
in  all  cases.  The  inverting  type  of  the  growth,  on  the  other  hand, 
whether  beginning  in  the  cervical  canal  or  in  the  vaginal  portion, 
usually  extends  to  the  vagina  by  way  of  the  lymphatics. 

The  pelvic  peritoneum  in  very  rare  cases  may  be  involved  at  an 
early  stage  of  the  disease.  Violet  and  Adler  have  reported  such  a 
case.  There  was  a  friable  cancerous  ulcer  in  a  freely  movable  uterus 
and  without  evidence  of  involvement  in  the  fornices.  When  the  abdo- 


FIG.  61. — POSTERIOR  VIEW  OF  FIG.  61.    EXTENSION  OF  CANCEROUS  MASSES  THROUGH  PERI- 
TONEUM OF  RIGHT  BROAD  LIGAMENT. 

men  was  opened,  however,  a  large  subperitoneal  metastatic  deposit  was 
found  in  the  subserous  tissue  of  the  lower  part  of  the  parietal  perito- 
neum extending  downward  into  the  bladder;  and,  in  addition,  there 
were  two  isolated  masses  the  size  of  a  cherry  which  were  found  in  the 
peritoneum  itself. 

THE  BLADDER. — The  muscular  coat  of  the  bladder  is  rarely  involved, 
except  in  the  very  late  stages  of  the  disease.  When  the  mucous  mem- 
brane is  invaded,  nodules  are  found  in  the  bladder,  usually  on  the  floor 
and  behind  the  trigonum.  Secondary  necrosis  of  a  cancerous  extension 
may  lead  to  the  formation  of  a  vesicovaginal  fistula. 


•  CARCINOMA  OF  THE  UTERUS  199 

The  ureters  are  frequently  affected  by  the  involvement  of  the  para- 
metrium  or  by  extension  from  the  base  of  the  bladder.  Compression 
of  the  lumen  is  common,  although  complete  obstruction  is  rare.  Hydro- 
ureter  frequently  results.  Leitch  found  this  condition  in  75  per  cent 
of  his  cases,  and  Albers-Schomberg  in  40.2  per  cent.  Even  in  the 
operable  cases,  the  results  of  this  compression  of  the  ureters  may  be 
so  considerable  as  to  interfere  with  the  success  of  the  operation.  While 
Wertheim  states  that  the  ureters  are  extremely  resistant  to  invasions, 
involvement  is  more  common  than  is  usually  considered.  As  the  pres- 
sure continues  following  the  dilatation  of  the  ureter,  there  is  back 
pressure  on  the  pelvis  of  the  kidney  which  may  progress  to  hydro- 
nephrosis.  Infection  of  the  bladder  and  ureters  is  common  as  a  sequel 
of  the  operation,  and  pyonephritis  may  occur  in  consequence. 

THE  RECTUM. — The  rectum  is  less  commonly  involved  than  is  the 
bladder,  possibly  because  of  the  protection  given  by  the  peritoneum  of 
the  posterior  cul-de-sac.  As  the  disease  progresses,  particularly  when 
the  cervical  canal  is  involved,  the  growth  extends  along  the  utero- 
sacral  ligaments,  and  the  wall  of  the  intestines  becomes  infiltrated. 
Recto-vaginal  fistulae  follow  the  breakdown  of  carcinomatous  exten- 
sions. 

The  ovaries  and  tubes  are  seldom  affected.  One  or  the  other  rarely 
may  be  involved  by  extension  through  the  lymphatics.  There  are 
various  channels  through  which  this  may  occur;  as  through  the 
lymphatics  in  the  myometrium;  more  commonly  by  lymphatics  along 
the  uterine  wall;  and  very  rarely  by  a  continuation  of  the  growth  to 
the  lumen  of  the  tube  from  the  uterine  cavity. 

THE  LYMPH  NODES. — The  uterine  lymphatics  vary  considerably  at  dif- 
ferent ages,  and  attain  full  development  during  adult  sexual  life,  reach- 
ing their  maximum  during  pregnancy  and  the  puerperium.  They  are 
small  and  few  before  puberty,  and  after  the  climacteric  they  diminish 
progressively  with  advancing  age.  '  This  latter  factor  is  of  clinical 
import,  and  explains  the  fact  that  corporeal  cancer,  occurring  as  it  does 
so  frequently  in  women  past  the  menopause,  grows  more  slowly  and 
tends  to  remain  localized  for  a  longer  period  than  does  the  cervical 
carcinoma  which  appears  before  the  end  of  sexual  activity. 

There  are  different  ideas  as  to  the  anatomical  distribution  of  the 
lymphatics  and  their  nodes.  The  lymphatics  of  the  uterus  rise  from 
three  channels,  that  is,  from  papillary  networks  in  the  mucous  mem- 
brane, in  the  muscular  coat,  and  in  the  peritoneum.  Poirier  and  Cuneo 
claim  that  there  is  a  connecting  trunk  which  runs  to  the  subperitoneal 
tissue,  and  anastomoses  on  the  surface  of  the  uterine  muscle  to  form 
a  fourth  network.  The  plexus  in  the  body  and  cervix  is  continuous 
without  any  demarcation  between.  There  are  no  definite  lymph 
channels  in  the  endometrium,  and  the  lymph  flows  in  unlined  spaces 
between  the  stroma  cells.  Occasionally,  there  are  endothelial  cells 


200  PELVIC  NEOPLASMS 

which  are  found  in  the  neighborhood  of  the  uterine  glands  and  on  the 
walls  of  the  blood  vessels  which  may  represent  undeveloped  lymph 
sheaths.  There  are  many  large  lymphatic  vessels  in  the  middle  and 
outer  walls  of  the  uterine  musculature,  which  lie'  together  with  the 
larger  blood  vessels,  and  which  communicate  with  the  endometrium 
and  the  lymphatics  of  the  cervix.  The  lymphatic  vessels  are  noticeably 
smaller  in  the  inner  muscular  layer. 

There  are  six  sets  of  regional  lymph  nodes  of  the  uterus  which  may 
be  involved  by  cancerous  processes:  (i)  parametric;  (2)  hypogastric; 
(3)  sacral;  (4)  lumbar;  (5)  iliac;  (6)  inguinal.  Each  group  consists 
of  from  three  to  five  individual  lymph  glands. 

There  are  also  a  number  of  lymphatic  nodules  in  the  parametrium : 
(i)  a  definite  node  in  the  parametrium  in  the  region  where  the  uterine 
artery  crosses  the  ureter;  (2)  a  number  of  very  small  glands  which 
are  scattered  through  the  parametrium ;  (3)  a  number  of  atypical  nodes 
which  seem  to  develop  in  the  walls  of  the  main  lymphatics  and  pro- 
trude like  a  sponge  into  their  lumen.  The  last  group  is  most  interest- 
ing and  appears  to  be  the  reason  why  the  outlying  lymph  glands  are  not 
more  commonly  involved. 

Baisch  describes  a  number  of  lymph  channels  which  drain  the  portio 
of  the  cervix  and  the  cervix  proper,  and  which  run  laterally  along  the 
inner  side  of  the  uterine  artery.  He  states  that  there  are  from  five  to 
eight  of  these,  which  properly  group  themselves  into  three  sets, 
because  they  empty  into  glands  in  three  different  areas.  The  first 
empties  into  the  iliac  glands  on  the  anterior  surface  and  inner  border 
of  the  external  iliac  artery,  near  the  hypogastric  artery  which  is  the 
anterior  branch  of  the  internal  iliac.  The  lowest  of  these  nodes  are 
also  described  as  obturator  lymph  glands.  The  second  set  runs  more 
posteriorly,  and  empties  into  the  hypogastric  lymph  nodes  on  the  in- 
ternal border  of  the  hypogastric  artery.  The  third  division  arises 
more  from  the  dorsal  side  of  the  cervix,  and  runs  back  over  the  pos- 
terior vaginal  fornix  to  the  uterosacral  ligaments  to  the  posterior  pelvic 
wall,  and  empties  into  the  glands  by  the  side  of  the  sacral  ganglia, 
and  occasionally  higher  up  and  more  in  the  median  line  just  beneath 
the  promontory. 

The  lymph  channels  of  the  uterine  body  are  arranged  in  four  or  five 
branches.  They  pass  through  the  broad  ligament  beneath  the  tube 
but  above  the  ovary,  and  run  alongside  the  ovarian  vessels  upward  and 
inward  to  end  in  the  lumbar  lymph  glands  just  above  the  bifurcation 
of  the  aorta.  In  addition  to  these,  the  main  branches  from  the  uterine 
body,  there  are  some  lymphatics  which  arise  near  the  middle  of  the 
uterus  and  join  partly  with  the  upper  lymph  tracts  of  the  cervix.  They 
finally  pass  along  the  round  ligaments,  and  empty  into  the  deep  and 
superficial  inguinal  lymph  glands. 


CARCINOMA    OF    THE    tTERUS 


201 


Due  to  the  anatomical  distribution  of  the  lymphatics,  the  para- 
metric, iliac,  hypogastric  and  sacral  lymph  glands  are  the  ones  most 
likely  to  be  involved  by  metastases  from  cervical  carcinoma.  These 
groups  of  glands  are  frequently  designated  as  the  first  or  lower  group, 
since  they  receive  the  first  cancer  cells  that  are  disseminated  through 
the  lymphatics.  The  lumbar  and  internal  and  external  inguinal  glands 
are  usually  termed  the  second  group.  They  are  more  likely  to  be  in- 
volved by  the  first  dissemination  of  cancers  from  the  body  of  the 
uterus,  although  they  may  be  affected  by  cervical  cancers,  which  have 
involved  the  first  group  with  a  dose  so  overwhelming  that  they  spread 
through  them  and  thence  into  the  second  group.  Unfortunately  we 
have  no  means  of  knowing,  before  microscopic  study,  when  the  pelvic 
glands  are  involved,  nor  the  laws  which  govern  metastases.  Mention 
has  already  been  made  of  the  fact  that  very  small  cancers  may  give 
rise  to  early  metastases,  while  large  growths  may  remain  localized 
occasionally  for  a  very  long  time.  It  is  usually  stated  that  in  the 
so-called  operable  cases,  pelvic  lymph  glands  are  already  involved  in 
from  30  per  cent  to  50  per  cent  of  cases.  These  figures  were  obtained 
by  the  microscopic  study  of  glands  removed  at  operation,  and  it  may 
be  that  they  are  too  low,  since  it  is  more  than  probable  that  many 
glands  were  overlooked  which  might  have  been  cancerous,  as  the  great 
majority  of  men  remove  only  the  large  palpable  glands.  The  follow- 
ing table  shows  the  frequency  in  which  the  glands  were  found  to  be 
cancerous  after  operation,  although  cancers  of  the  cervix  and  of  the 
uterine  body  have  been  included  by  the  authors  in  their  series.  This 
is  most  regrettable  since,  as  we  have  already  seen,  cancers  of  the 
cervix  differ  markedly  from  those  of  the  uterine  body,  both  in  their 
methods  of  invasion  and  their  malignancy. 


GLANDS  FOUND  CANCEROUS  AFTER  OPERATION 


Authority 

Per  cent 

Number  of  cases 

von  Rosthorn  .  .  . 

4.2  .4 

28  cervical  cancers 

Wertheim  

28 

Doederlein      

•2? 

Bumm  

72.7 

32  cervical  cancers 

Sampson  

64 

27 

Pankow  

28.2 

70  cases  (67  cervical) 

Doederlein      

22.8 

115  cases  (types  not  stated) 

Kleinhaus  

28 

~2     "         n.        «        <  < 

Glockner  (Zweifel)        

3O 

«         "        «        « 

Freund                        

25  8 

Schottlaender  

43 

Types  not  stated  (presumably  cervical) 

Berkeley  and  Bonnev  

3  ^ 

100  cases  (types  not  stated) 

Brunet  

•5-> 
ci 

47  cases  (types  not  stated,  presumably  cervical) 

202  PELVIC  NEOPLASMS 

Cancer  is  found  in  lymph  glands  with  varying  frequency.  Un- 
less the  entire  gland  is  studied  by  serial  sections  microscopically,  the 
disease  may  easily  be  overlooked.  This  has  been  well  shown  by  Ries 
who  demonstrated  a  very  small  gland  which  was  cut  in  more  than  300 
serial  sections.  Cancer  was  present  only  on  the  last  25  slides. 

The  parametrium  is  usually  affected  before  there  is  metastasis  to 
the  lymph  glands.  Indeed,  it  would  seem  as  if  the  parametria  had 
che.cked  at  least  temporarily  the  extension  in  certain  cases.  The  small 
gland  near  which  the  uterine  artery  is  crossed  by  the  ureter  is  involved 
in  nearly  all  cases.  Sampson  has  shown  that  the  small  discrete  glands 
in  the  parametrium,  which  lie  at  some  distance  from  the  uterus,  are 
also  invaded  nearly  uniformly.  Moreover,  it  would  appear  as  if  the 
lymphoid  tissue,  which  hangs  down  in  the  lumen  of  the  lymphatics, 
blocks  a  large  number  of  cells  in  their  progress  toward  the  pelvic 
lymph  glands.  Kundrat  observed  this  condition  in  15  of  80  cases. 
Sampson  found  similar  involvement  in  4  of  27  cases,  although  distant 
metastases  were  present  in  3  of  them.  On  the  other  hand,  the  cancer 
cells  may  pass  through  the  lymphatics  of  the  parametrium  without  in- 
volving them,  and  not  become  lodged  until  they  are  arrested  by  the 
pelvic  lymph  glands.  This  has  been  proved  by  study  of  serial  sections 
of  the  parametria.  Sampson  observed  cancerous  involvement  by  such 
study  in  3  of  10  cases  in  which  the  parametria  were  free.  Kundrat 
found  that  10  per  cent  of  one  series  of  Wertheim's  cases  had  cancerous 
lymph  glands,  although  the  parametrium  was  not  involved.  We  have 
already  alluded  to  the  method  in  which  the  cancer  grows  about  the 
lymph  glands.  The  deported  cells  are  swept  along  in  the  structures 
of  the  lymph  glands  until  they  are  arrested  by  a  small  duct.  Other 
cells  come  on  from  behind.  Since  they  cannot  pass  further,  they  grow 
back  in  the  lymphatic  channels  until  they  have  increased  to  a  mass 
of  sufficient  size  to  break  through  the  channels  and  involve  the  neigh- 
boring tissues. 

Cancerous  invasion  of  the  lymph  glands  can  be  proved  only  by  micro- 
scopic study  of  serial  sections,  since  the  glands  are  usually  enlarged  from 
absorption  of  toxic  products  from  the  cancerous  ulcer.  They  may  be  en- 
larged from  other  conditions,  as  tuberculosis.  Schottlaender  found  enlarged 
tuberculous  glands  in  3  cases  of  his  cancer  series. 

The  older  literature  indicates  that  pelvic  lymph  glands  are  not 
invaded  in  a  definite  order.  Careful  work  done  during  the  last  gene- 
ration'has  proved  that  as  a  rule  this  is  an  error,  although  Sampson's 
finding  is  to  the  contrary.  The  majority,  however,  believe  that  the 
older  findings  were  largely  vitiated  by  grouping  together  of  both 
cervical  and  uterine  cancers,  as  well  as  by  the  mixture  of  autopsy 
cases  with  those  that  had  been  operated.  Baisch  has  shown  that  meta- 
stases to  the  lymph  glands  'in  cervical  carcinoma  follow  the  physio- 


CARCINOMA   OF   THE   UTERUS  203 

logical  and  anatomical  distribution,  that  there  is  no  break  in  the  chain, 
and  that  the  second  or  remote  group  of  lymph  glands  is  not  involved 
except  in  very  rare  cases  when  the  first  or  lower  group  is  free. 
Oehlecker,  Vinay,  and  others  have  shown  that  the  second  group  of 
lymph  glands  usually  show  a  simple  hyperplasia  when  the  first  or  lower 
set  are  involved  by  a  cancer.  When  the  disease  has  extended  com- 
pletely through  the  first  group,  the  second  group  also  becomes  carci- 
nomatous.  Baisch,  in  52  cases  of  cervical  carcinoma,  which  he  studied, 
was  not  able  to  find  one  in  which  the  lower  and  upper  sets  of  lymph 
glands  were  simultaneously  involved;  nor  did  Winter,  in  45  cases; 
nor  Oehlecker  in  7,  except  in  autopsy  cases,  and  in  cancers  of  the 
uterine  body.  Leitch,  who  has  investigated  the  records  of  915  com- 
plete post  mortems  of  cancer  of  the  cervix,  emphasizes  the  importance 
of  the  interiliac  glands  in  the  extension  of  cancer. 


GENERAL  METASTASES       . 

The  possibility  of  a  general  dissemination  of  carcinoma  is  not  fre- 
quent in  the  early  cases,  and  usually  the  patients  die  before  there  is 
a  general  metastatic  invasion.  There  are,  as  yet,  no  large  compila- 
tions which  consider  metastases  in  the  various  types  of  uterine  cancer 
such  as  the  portio  vaginalis,  the  cervical  canal,  and  the  fundus.  The 
value  of  the  older  tables  is  impaired  because  all  types  of  uterine  cancer 
have  been  included  together.  In  79  autopsy  cases  of  uterine  cancers, 
all  groups,  Williams  noted  the  following  sites  of  metastatic  invasion: 

Cases 

In   the  lung    7 

In  the  liver    7 

In  the  peritoneum  and  omentum 4 

In  the  pleura    2 

In  the  skin  of  breast  and  abdomen I 

In  the  tibia  and  innominate  bone i 

In  the  heart   i 

In   the  kidney    i 

In  225  cases  of  uterine  cancer  of  all  groups,  Blau,  Dybowski,  and 
Wagner  found  the  following  parts  of  the  body  were  involved  by 
metastases : 


204  PELVIC   NEOPLASMS 

Per  cent          Cases 

In  the  liver    9                  24 

In  the  lung 7                   18 

In  the  kidney    3^2                9 

In  the  stomach    4 

In  the  intestines    4 

In  the  thyroid    5 

In  the  brain    i 

In  the  adrenal    I 

In  the  skin    I 

In  the  gall-bladder    I 

In  the  heart   i 

In   the  breast    i 

In  abdominal  muscle i 

In  pelvic  bones i 

Offergeld,  in  1908,  states,  as  a  result  of  his  study  of  carcinoma  of 
the  uterus,  that  metastases  to  the  brain  may  occur  relatively  often. 
He  collected  20  cases  of  metastases  to  the  brain  and  5  cases  of  meta- 
stases to  the  dura  from  the  literature.  He  thought  that  metastases 
of  the  osseous  system  were  determined  by  the  blood  system  of 
the  bone  and  its  static  peculiarity.  Bony  metastases  occur  by  way 
of  the  arterial  system,  and  rarely  by  retrograde  venous  transplan- 
tation. There  was  no  evidence  of  osteoplastic  formation,  and  the 
clinical  symptoms  of  the  bony  metastases  were  identical  with  those 
produced  by  a  tumor,  that  is,  nerve  irritation  and  the  tendency  for 
spontaneous  fractures  of  the  bone.  He  emphasizes  the  fact  that  occa- 
sionally men  have  been  confused  in  their  differentiation  between  the 
glandular  involvement  in  advanced  cervical  carcinoma  and  general 
metastases.  He  found  the  favorite  site  of  peritoneal  metastases  was 
the  pouch  of  Douglas  and  the  vault  of  the  diaphragm.  The  secondary 
nodules  in  the  omentum  and  the  walls  of  the  intestines  originated  from 
the  lymphatics.  Some  of  the  peritoneal  involvements  did  not  cause 
symptoms;  in  the  remainder  of  the  cases,  the  complaints  originated 
from  the  presence  of  the  intra-abdominal  tumor,  chronic  peritonitis, 
or  stenosis  of  the  bowel.  The  liver  may  be  involved  in  from  5  per  cent 
to  15  per  cent  of  uterine  cancers  and  the  metastases  may  appear  early 
or  late.  The  involvement  may  follow  through  the  lymphatics  or  hema- 
togenous  systems.  It  is  favored  by  the  double  blood  supply  of  the 
liver,  consisting  of  the  inferior  hemorrhoidals,  portal  vein,  and  the 
hepatic  artery.  The  lymphatic  supply  consists  of  radicals  around  the 
portal  vein  and  tributaries  in  the  pelvic  and  mesenteric  lymph  glands. 
Offergeld  believed  that  liver  involvement  is  not  more  frequent  because 
the  hepatic  cells  possess  a  biological  fermentative  activity  which  tends 
to  destroy  the  cancer.  Offergeld's  review  is  painstaking  and  thorough, 


CARCINOMA  OF   THE   UTERUS 


205 


and  he  divides,  wherever  possible,  the  primary  growths  according  to 
their  situation  in  the  cervix  and  in  the  body  of  the  uterus. 


SYMPTOMS  OF  CARCINOMA  OF  THE  CERVIX 

The  disease,  unfortunately,  develops  in  a  very  insidious  manner. 
Proof  that  the  symptoms  of  the  early  cancer  are  slight  is  shown  by  the 
fact  that  a  large  proportion  of  the  cases  are  inoperable  when  first  seen 
by  the  physician.  The  average  duration  of  symptoms  before  therapeu- 
tic measures  were  undertaken  in  a  large  statistical'  series  was  six 
months.  Others  state  that  it  is  longer.  Thus  Farr  found  the  average 
period. from  the  onset  of  symptoms  to  the  first  consultation  with  a 
physician  was  3.2  months  in  a  series  of  103  cases  in  New  York  City, 
and  the  average  time  from  this  time  to  their  entrance  into  the  hospital 
was  8.7  months.  He  obtained  an  average  of  11.9  months  from  the 
onset  of  symptoms  until  the  patient  entered  the  hospital  for  active 
treatment.  Farr's  study  emphasizes  the  point  that  because  of  many 
delays,  patients  in  America  seldom  present  for  treatment  while  the 
growth  is  operable.  Wertheim  emphasized  the  fact  that  only  15  per 
cent  of  the  cases  presenting  in  his  clinic  in  Vienna  were  operable  when 
he  first  began  his  studies  of  cancer.  In  spite  of  the  interest  which  has 
recently  been  created  in  cancer,  less  than  10  per  cent  come  for  treat- 
ment to  our  clinic  in  the  stage  that  can  be  treated  successfully  by  oper- 
ation. The  percentage  of  operability  for  carcinoma  of  the  cervix  varies 
greatly  in  the  hands  of  different  surgeons.  Some  men  undertake  to 
operate  all  cases,  while  others  restrict  surgical  measures  to  the  type  of 
case  which  alone  affords  good  chance  of  cure  and  do  not  believe  in  the 
so-called  palliative  operation.  With  this  point  in  mind,  we  should 
study  the  following  table  : 

PERCENTAGE  OF  OPERABILITY 


European 

Per  cent 

American 

Per  cent 

Berkeley  and  Bonney  

67 

Peterson 

20 

Bumm           

90 

Jonas 

so 

Doderlem                    

68 

Cannady 

eo 

Franz         

81 

Smith 

20 

Teannel                

3° 

Janvrin 

10 

Kromsr             

87 

Tate 

1C 

Klein                

4° 

Cunston 

c 

Kuestner        

68 

Frank 

25 

Lockyer                 

7° 

Mackenrodt          

92 

Mueller                    

89 

Polosson              

56 

Reimcke                  

40 

von  Rosthorn         

36 

60 

206  PELVIC  NEOPLASMS 

The  classical  symptoms  are  leukorrhea  and  hemorrhage.  These 
should  be  emphasized,  since  it  is  self-evident  that  the  symptoms 
peculiar  to  late  cases  should  not  be  considered  when  reviewing  oper- 
able growths.  Much  of  the  confusion  which  exists  in  the  minds  of  the 
general  medical  profession  has  resulted  from  the  fact  that  operable 
and  inoperable  cancers  are  usually  considered  together. 

Leukorrhea. — This  is  rarely  the  ordinary  mucous  discharge,  but 
usually  is  a  watery  irritating  discharge  which  may  excoriate  the  vaginal 
mucous  membrane  and  tissues  with  which  it  comes  in  contact.  It  is 
composed  of  serum,  and  may  present  the  ordinary  characters  found 
in  connection  with  endocervicitis.  Leukorrhea  was  present  in  75  of 
Waldstein's  cases,  and  constituted  the  first  symptom  in  45  of  78  cases 
analyzed  by  Craig.  Later  in  the  disease,  its  color  varies  from  yellow, 
brown,  and  green  to  bloodstained,  depending  upon  the  type  of  bacterial 
invasion.  A  characteristic  fetid  odor  develops  when  ulceration  has 
occurred. 

Hemorrhage. — This  is  the  first  symptom  noticed  in  about  two- 
thirds  of  the  cases,  and  may  appear  in  women  in  apparently  good 
health.  Naturally,  hemorrhage  assumes  greater  importance  after  the 
menopause,  since  the  great  majority  of  women  know  that  this  is 
usually  associated  with  malignant  conditions.  We  believe,  however, 
that  changes  in  menstruation  may  be  equally  important,  since  Wert- 
heim  has  shown  that  nearly  55  per  cent  of  his  first  500  cases  developed 
while  the  woman  was  still  in  active  sexual  life  (under  45  years  of 
age).  The  bleeding  comes  from  bursting  of  capillaries  in  cancerous 
nodules,  and  may  follow  a  comparatively  slight  trauma,  such  as  douch- 
ing, coitus,  or  defecation.  Quite  naturally,  everting  growths  call  atten- 
tion to  their  presence  by  means  of  hemorrhage  earlier  than  do  the  in- 
verting forms.  There  may  be  no  bleeding  from  the  latter  type  of 
cases  until  there  has  been  widespread  ulceration  and  extensive  involve- 
ment of  the  uterus  and  parametrium.  Occasionally  the  only  symptom 
is  a  profuse  and  prolonged  menstruation.  Waldstein  found  atypical 
uterine  bleeding  as  the  early  symptom  in  120  of  219  cases,  the  symp- 
toms consisting  either  of  a  slight  flow  between  periods,  or  in  an  increase 
in  the  amount  at  the  regular  menstruation.  Sampson  stated  that 
bleeding  or  a  bloodstained  discharge  was  present  in  93  per  cent  of  412 
cervical  cancers  in  Kelly's  clinic ;  in  60  per  cent  of  these  there  was  a 
history  of  bleeding  for  more  than  six  months  before  the  patient  sought 
medical  advice.  Hemorrhage  was  the  first  symptom  in  21  of  78  cases 
collected  by  Craig. 

Patients  frequently  complain  of  irritability  of  the  bladder  as  an  initial 
symptom,  and  less  frequently  of  rectal  tenesmus.  Vulvar  irritation 
from  the  leukorrhea  may  also  be  one  of  the  first  symptoms  of  the 
disease.  Pain  is  not  an  early  symptom,  and  does  not  occur  until  the 


CARCINOMA   OF   THE   UTERUS  207 

uterine  wall  and  parametrium  have  become  infiltrated  by  the  absorp- 
tion from  an  infected  ulcer. 

It  is  unfortunate  that  the  symptoms  of  this  disease  are  not  charac- 
teristic. Not  uncommonly,  the  increase  in  nutrition  and  general  well- 
being,  which  may  follow  the  menopause,  obscures  the  insidious  onset. 
Even  fairly  intelligent  and  observant  women  are  unable  often  to  give 
a  history  of  symptoms  which  date  back  more  than  a  few  weeks.  The 
laity  universally  believe  that  cancer  cannot  develop  without  pain, 
and  that  irregular  bleeding,  and  even  hemorrhage,  are  characteristic 
of  the  menopause,  an  opinion  which  is  readily  confirmed  by  physicians 
who  are  not  conversant  with  the  disease.  The  only  way  to  improve 
the  mortality  is  to  combat  the  ignorance  which  prevails  concerning 
the  early  symptoms  of  the  disease. 

Clinical  Course. — In  the  very  early  stages  the  patient's  general  con- 
dition is  usually  very  good;  indeed,  a  gain  in  weight  is  not  unusual,  a 
point  already  mentioned.  Occasionally,  however,  the  patient  may 
complain  of  lassitude,  loss  of  strength  or  weight,  which,  however,  re- 
sults more  frequently  from  other  conditions  than  from  the  early 
cancer.  In  the  vast  majority  of  cases  the  woman  is  not  concerned 
over  the  appearance  of  a  bloody  discharge,  attributing  it  to  a  reap- 
pearance of  the  catamenia,  if  the  menopause  has  already  occurred,  or 
to  the  all-prevailing  idea  that  irregularities  or  alterations  in  the  char- 
acter of  the  bleeding  are  normal  consequences  of  the  climacteric.  The 
findings  of  examination  in  the  early  stages  vary  with  the  site  and 
character  of  the  neoplasm.  The  everting  carcinoma  will  present  only 
as  a  small  polypoid  excrescence,  and  rarely  as  a  slightly  raised  broad 
plaque.  The  color  of  the  growth  is  whitish  and  opaque,  or  else  yel- 
lowish red.  The  consistency  varies,  but  is  usually  less  firm  than  normal 
tissue.  It  is  friable  and  bleeds  readily  at  the  slightest  touch.  In  the 
inverting  type  there  may  be  only  negative  findings.  The  involved  lip 
of  the  cervix  is  hypertrophied,  and  occasionally  a  hard  mass  may  be 
felt  within.  The  surface  may  be  slightly  granular,  and  induration 
and  puffing  may  be  the  only  feature  observed.  There  is  little  tend- 
ency to  bleed.  In  nearly  two-thirds  of  the  cases  of  cervical  cancer 
which  are  operable,  there  is  some  ulceration,  usually  in  the  region  of 
the  external  os.  The  border  of  the  ulceration  is  elevated,  irregular, 
and  firm.  The  base  is  depressed,  and  is  covered  with  small  granular 
elevations,  often  surmounted  with  a  grayish  yellow  exudate.  The 
symptoms  common  to  all  ulcers  are  present,  namely,  discharge  and 
bleeding. 

When  the  disease  begins  in  the  cervical  canal,  the  external  os  is 
patulous,  and  just  within  it  may  be  felt  the  friable  papillary  excrescence 
or  the  hard,  irregular  ridge  forming  the  border  of  a  carcinomatous 
ulcer  within  the  canal.  The  supravaginal  cervix  may  be  thickened  and 
indurated,  and  beginning  lateral  extensions  may  diminish  the  mobility 


208  PELVIC   NEOPLASMS 

of  the  uterus.  Frequently,  however,  the  parametric  thickenings  have 
resulted  only  from  absorptions  from  the  infected  ulcer.  If  the  neo- 
plasm begins  as  a  central  nodule,  the  cervix  feels  hard  and  enlarged 
because  of  the  carcinomatous  area  within  its  walls.  If  the  mucous 
membrane  is  not  involved,  it  may  appear  normal,  yet,  more  commonly, 
it  is  fixed  over  the  nodule  and  is  puckered  because  of  the  induration. 

The  second  stage  represents  the  border-line  case  of  operability.  The 
ulceration  advances,  and  there  is  considerable  induration  of  the  parame- 
trium  which  fixes  the  uterus,  usually  to  the  left  side.  Hemorrhages  are 
more  common,  and  may  come  on  without  warning  or  may  follow  slight 
trauma.  Vaginal  discharge  is  present,  at  first  thin,  watery,  and  irritating, 
and  usually  with  a  disagreeable  odor  as  a  result  of  secondary  infection  of 
the  ulcer.  Even  at  this  stage  the  patient's  condition  is  good.  Some  look 
the  picture  of  health,  while  others  present  anemia  and  loss  of  strength,  if 
there  has  been  frequent  hemorrhage.  Pain  is  usually  absent,  although  dis- 
comfort or  dull  gnawing  sensations  are  noted  in  the  pelvis  or  back. 

The  third  stage  represents  the  inoperable  condition.  There  is  a  marked 
impairment  of  general  strength.  The  skin  frequently,  but  by  no  means 
always,  exhibits  the  yellow,  white,  cachectic  appearance  so  characteristic 
of  malignancy.  Klemperer  claims  that  this  is  due  to  the  fact  that  more 
nitrogen  is  excreted  than  is  received,  largely  because  of  the  presence  of 
infection.  Hemorrhages  are  frequent  and  profuse,  and  a  foul  vaginal 
discharge  is  present  in  the  intervals  between  the  bleeding.  Up  to  this 
point  the  symptoms  are  chiefly  those  resulting  from  the  presence  of  an 
infected  ulcer.  With  the  extension  of  the  growth  to  the  neighboring  struc- 
tures, and  with  the  involvement  of  the  nerve  sheaths,  pain  becomes  severe. 
It  may  be  either  knifelike  and  darting,  radiating  to  the  hips,  thighs,  and 
calves  of  the  legs,  or  occasionally  only  a  steady,  dull,  constant  ache  in  the 
pelvis.  Involvement  of  the  bladder  is  often  ushered  in  by  hematuria,  when 
a  cystoscopic  examination  may  reveal  carcinomatous  nodules  in  the  trigo- 
num.  Dribbling  of  urine  generally  indicates  a  vesicovaginal  fistula,  or  a 
ureterovaginal  fistula.  When  the  growth  spreads  posteriorly,  defecation 
becomes  painful,  and  occasionally  a  rectovaginal  fistula  occurs.  Colitis 
is  a  common  sequela  of  fecal  impaction  and  large  quantities  of  mucus  may 
signify  its  advent.  Other  intestinal  symptoms,  as  nausea  and  vomiting,  are 
frequent.  Intestinal  obstruction  is  not  rare.  Uremia  threatens  in  the  ter- 
minal stages,  the  intellect  becomes  dull,  and  edema  of  the  face  and  extremi- 
ties occurs.  Fever  is  present  from  absorption  of  infected  material  from  the 
ulcer  and  carcinomatous  protein.  Death  may  result  from  acute  hemor- 
rhage, but  is  more  commonly  due  to  some  terminal  infection,  as  pneumonia 
or  septicemia,  less  frequently  to  multiple  thromboses  or  extensive  renal 
disease.  Shortly  before  the  end,  the  pain  may  become  so  severe  that  it 
cannot  be  controlled  by  morphine. 

Diagnosis. — Unfortunately,  the  dictum,  "the  more  certain  the  diag- 
nosis, the  less  the  probability  of  cure,"  holds  true  for  all  forms  of 


CARCINOMA    OF    THE    UTERUS  209 

cancer  of  the  uterus,  and  early  diagnosis  is  the  most  important  factor 
in  the  control  of  the  disease.  It  is  far  better  to  regard  all  suspicious 
cases  as  malignant  until  proved  otherwise.  Delay  often  loses  the 
patient  the  chance  of  cure  by  operation.  A  grave  responsibility  is  laid 
upon  the  physicion  to  examine  thoroughly  every  suspicious  case. 
The  importance  of  microscopic  diagnosis  is  emphasized  by  all  authors, 
yet  the  great  majority,  unfortunately,  do  not  qualify  the  method  by 
which  the  microscopic  diagnosis  can  be  made.  In  uterine  cancer,  as 
in  cancer  in  general,  there  is  usually  little  difficulty  in  determining  the 
fact  that  visible  growths  are  malignant.  Much  harm  may  be  done  by 
removing  tissues  for  microscopic  sections  in  cancerous  tissues,  and 
delaying  operation  until  the  report  of  a  pathologist  may  be  obtained. 
Nearly  every  surgeon  has  long  known  that  removal  of  cancerous  tissue 
from  the  breast  should  be  followed  by  immediate  operation,  if  he  would 
not  lose  for  the  patient  the  chance  of  cure,  since  the  disease  may  be 
stimulated  to  most  active  growth  by  incision  of  its  tissue.  The  careful 
surgeon,  therefore,  will  not  remove  suspicious  areas  from  a  cervix 
unless  they  can  be  examined  by  frozen  sections,  and  the  diagnosis 
followed  by  immediate  operation  after  the  lapse  of  a  very  few  minutes 
of  time.  All  surgeons  should  bear  in  mind  that  at  the  present  time 
we  believe  that  only  early  cancers  are  curable  by  operation,  and  in- 
complete operations  should  not  be  attempted  if  the  diagnosis  is  final. 
Unfortunately,  there  may  be  no  symptoms  until  a  large  craterlike 
ulcer  has  formed  and  the  cervix  is  entirely  eaten  out  by  extensive  in- 
volvement (inverting  type  of  carcinoma).  Suggestive  symptoms,  how- 
ever, should  be  the  indication  for  an  exhaustive  investigation.  These 
are  the  following: 

1.  Intermenstrual  bleeding  or  any  deviation  from  the  normal, 
particularly   in  women   at  the   menopausal  age  who  have  borne 
children.      Cervical    carcinoma,    however,    may   appear   in   young 
women  who  have  not  borne  children. 

2.  Return   of  bleeding  after  the   menopause  has  been   estab- 
lished. 

3.  Bleeding  after  slight  trauma  from  douching,  defecation,  or 
coitus. 

4.  Appearance  of  leukorrhea  in  a  woman  as  a  new  symptom, 
or  alteration  in  the  amount  and  character  of  the  previous  vaginal 
discharge.      Especially   significant   is   a   watery,   acrid,   or   blood- 
stained discharge. 

5.  Pelvic  pain.     This  is  rarely  an  early  symptom. 

The  findings  of  internal  examination  will  depend  upon  the  extent  and 
location  of  the  neoplasm.  On  the  surface  of  the  cervix  or  at  the  lower  end 
of  the  canal  at  the  external  os,  the  tumor  is  accessible  to  sight  and 


2io  PELVIC   NEOPLASMS 

touch;  if  the  growth  is  situated  in  the  upper  part  of  the  canal,  the 
diagnosis  is  much  more  difficult. 

The  vulva  may  appear  perfectly  normal,  although  not  infrequently, 
even  in  early  growths,  there  may  be  evidence  of  irritation  and  excori- 
ation of  the  skin,  from  an  irritating  cervical  discharge.  Vaginal  exam- 
ination usually  shows  the  presence  of  a  cervical  enlargement.  This 
may  take  the  form  of  a  prominent  outgrowth  extending  above  the  gen- 
eral level  of  the  surface,  or  the  swelling  may  be  in  one  wall  displacing 
the  external  os  toward  the  other  side,  or  the  entire  cervix  may  be 
thickened.  Naturally  the  cases  which  present  at  the  external  os  and 
the  vaginal  portion  of  the  cervix  are  more  easily  recognized  than  those 
which  begin  in  the  cervical  canal.  Rarely  are  the  everting  forms  seen 
at  the  time  when  the  growth  consists  merely  of  delicate,  fingerlike 
processes.  An  important  finding  is  hemorrhage  which  may  come  on  at 
the  gentlest  touch.  Yet  it  is  important  to  remember  that  cases,  in 
which  the  tumor  develops  in  the  cervical  canal,  or  manifests  itself  as 
a  nodular  area  either  in  this  situation  or  on  the  cervix,  may  not  bleed 
until  the  growth  has  so  progressed  that  ulceration  occurs.  In  addition 
to  the  hypertrophy  of  the  cervix,  the  affected  area  usually  loses  its 
resilience,  becomes  hard,  inelastic  and  boardlike. 

As  the  growth  continues,  the  vaginal  fornix  and  the  entire  cervix 
may  be  the  seat  of  a  well-defined  ulceration  or  a  cauliflowerlike  growth. 
The  everting  type  of  cervical  carcinoma  is  the  more  easily  recognized, 
because  it  gives  symptoms  earlier,  but  it  is  more  rare,  and  usually  is 
not  as  malignant  as  the  inverting  type,  which  ulcerates  later,  and  con- 
sequently presents  symptoms  only  in  the  more  advanced  stages.  It 
is  important  to  remember  that  there  may  be  extensive  inverting 
growths  which  appear  to  sight  only  as  a  small  nodule,  or  as  a  limited 
ulcerated  area  either  around  the  os  or  in  the  canal;  and  yet  the  disease 
may  have  progressed  so  far  that  the  parametrium  is  already  exten- 
sively involved.  Sloughing  later  exposes  the  limits  of  the  neoplasm. 
Occasionally,  the  appearance  of  the  os  will  give  us  an  idea  as  to  the 
extent  of  the  involvement,  and  the  type  of  the  cancer.  Any  puckering 
or  retraction  of  areas  on  the  vaginal  cervix  should  arouse  our  suspi- 
cions, as  should  any  nodules  which  are  not  nabothian  follicles.  On  ex- 
posing the  cervix,  we  find  that  it  appears  more  glazed  than  the  normal 
cervix.  If  ulceration  is  present,  its  color  varies  from  a  yellow  to  a 
greenish  black,  and  the  borders  are  raised,  jagged  and  irregular.  In 
the  nodular  type,  the  mucous  membrane  covering  the  surface  usually 
presents  a  bluish,  mottled  appearance.  When  the  symptoms  point  to  a 
carcinoma  which  has  not  yet  undergone  ulceration,  the  cervical  canal 
may  be  curetted,  or  a  section  may  be  removed  from  the  cervix  and 
studied  by  frozen  section,  provided  only  that  the  radical  operation 
can  be  done  immediately  after  the  diagnosis  of  cancer  has  been  firmly 
established. 


CARCINOMA   OF   THE   UTERUS  211 

Differential  Diagnosis. — The  following  conditions  may  be  con- 
founded with  cervical  carcinoma :  Congenital  ectropion,  eversion  of  the 
cervix,  erosion,  ulceration  of  the  cervix  associated  with  prolapse, 
simple  hypertrophy  of  the  cervix,  lacerations  of  the  cervix,  cervical 
polypi,  submucous-  fibroid  polyps,  tuberculosis  of  the  cervix,  syphilis 
of  the  cervix,  condyloma  of  the  cervix,  diphtheritic  patches,  sarcoma 
of  the  cervix,  retained  portions  of  placenta,  and  endothelioma  of  the 
cervix. 

CONGENITAL  ECTROPION. — In  nullipara  it  is  not  unusual  to  find  a 
sharply  defined  red  zone  about  the  external  os.  It  varies  in  width  from  2 
milimeters  to  i  centimeter  and  appears  to  be  continuous  with  the  vaginal 
mucosa.  This  red  color  stands  out  in  marked  contrast  to  the  bluish  white 
appearance  of  the  vaginal  portion  of  the  cervix.  The  area  feels  granular, 
yet  there  is  no  induration  and  no  tendency  to  bleed.  Microscopic  sections 
show  a  normal  cervix  covered  by  a  single  layer  of  high  cylindrical  cervical 
epithelium. 

EVERSION  OF  THE  CERVIX. — This  condition  is  akin  to  the  preceding.  It 
differs  chiefly  because  the  cervical  mucosa  has  become  everted  by  lacera- 
tions of  the  cervix.  It  is,  therefore,  found  most  commonly  in  multipara. 
The  mucosa  is  bright  red  in  color,  and  there  is  a  clear  line  of  demarcation 
between  it  and  the  vagina,  although  the  outline  is  often  irregular.  This 
condition  is  often  confused  with  ulceration,  and  is  treated  locally.  In  such 
cases  there  results  a  distinct  proliferation  of  the  cylindrical  epithelium 
which  is  normally  but  one  layer  in  thickness.  There  is  no  induration,  nor 
does  bleeding  follow  examination. 

EROSION. — Properly  speaking,  this  terms  signifies  a  loss  of  substance 
and  should  be  limited  to  cases  in  which  this  condition  is  present.  Erosions 
may  be  a  precursor  of  carcinoma,  and  should  be  regarded  with  suspicion 
until  their  true  nature  is  proved.  Emmet  years  ago  called  attention  to  the 
fact  that  there  are  very  few,  if  any,  benign  ulcers  on  a  lacerated  cervix. 

ULCERATION  OF  THE  CERVIX  NONMALIGNANT,  ASSOCIATED  WITH  PRO- 
LAPSE.— -Simple  ulceration  is  seen  occasionally  in  prolapsed  uteri  when  it 
results  from  the  trauma  which  follows  this  condition.  The  cervix  is  usually 
hypertrophied,  and  the  vaginal  epithelium  assumes  the  appearance  of  skin 
as  a  result  of  evaporation  of  the  normal  transudates  and  from  the  exposure 
to  the  air.  There  may  be  one  or  several  ulcers  which  present  a  punched-out 
appearance  and  irregular  contour.  The  ulcers  are  soft  and  the  floor  shows 
a  typical  granulating  surface.  They  are  readily  dissected  out  and  are  very 
shallow.  Rarely  they  are  the  seat  of  carcinomatous  changes. 

HYPERTROPHY  OF  THE  CERVIX. — When  the  cervix  is  hypertrophied 
and  studded  with  nabothian  cysts  and  is  the  seat  of  a  chronic  inflammation, 
the  condition  may  readily  be  confused  with  inverting  cancers,  especially 
if  the  cysts  are  large  and  lie  in  the  depths  of  an  enlarged  and  indurated 
cervix.  In  case  of  doubt,  a  microscopic  diagnosis  is  indicated,  made  by 
frozen  sections  in  the  operating  room.  Occasionally  under  the  microscope 


212  PELVIC   NEOPLASMS 

the  cervical  mucosa  is  thickened,  and  presents  papillae  which  are  elongated 
and  branching.  There  are,  however,  no  downgrowths  of  epithelial  cells 
which  penetrate  the  basement  membrane,  nor  are  there  mitotic  figures. 

LACERATIONS  OF  THE  CERVIX. — Stellate  lacerations  of  the  cervix  in 
early  pregnancy,  when  the  cervical  tissue  is  smooth  and  soft  and  gives  the 
appearance  of  being  friable,  may  suggest  carcinoma.  Often  on  a  gaping 
lacerated  cervix  one  finds  small  papillary  areas  which  are  the  result  of  an 
endocervicitis,  and  which  at  first  sight  may  be  confused  with  cervical 
cancer.  The  tissue,  however,  does  not  bleed  readily.  The  microscopical 
picture  gives  the  typical  structure  of  the  cervical  endometrium. 

CERVICAL  POLYPI. — Mucous  polyps  projecting  from  the  cervix  may 
give  rise  to  bleeding.  The  polyp  itself  is  firm  in  contradistinction  to  the 
friable  tissue  of  the  carcinoma.  Examination  shows  that  they  usually 
spring  a  short  distance  within  the  cervical  cavity,  and  that  the  cervical 
lips  are  not  ulcerated  nor  thickened  as  they  are  in  malignant  conditions. 
In  case  of  doubt,  microscopic  diagnosis  is  indicated  by  frozen  sections 
taken  in  the  operating  room. 

SUBMUCOUS  FIBROIDS. — A  fibroid  polyp  lying  within  the  cervical  canal 
may  present  symptoms  of  hemorrhage,  discharge,  and  tissue  necrosis. 
Careful  examination,  however,  reveals  the  character  of  the  mass  sur- 
rounded by  the  intact  cervical  canal. 

TUBERCULOSIS  OF  THE  CERVIX. — The  symptoms  of  tuberculosis  of  the 
cervix  may  resemble  closely  carcinoma  in  the  same  region,  since  they  result 
from  the  presence  of  an  ulcer.  Hemorrhage,  however,  is  a  less  marked 
feature.  Tuberculous  ulcers  are  well  defined  and  have  undermined  edges. 
The  base  of  the  ulcer  is  studded  with  nodules,  is  pale  and  anemic  in  appear- 
ance, and  frequently  is  covered  with  caseous  material.  Induration  is  not 
as  marked  as  it  is  in  malignant  conditions.  Microscopic  examination  made 
by  frozen  section  in  the  operating  room  will  reveal  the  presence  of  giant 
cells  and  tubercles. 

SYPHILIS  OF  THE  CERVIX. — This  may  present  in  three  forms: 

(a)  Primary  chancres.  These  are  rare,  although  not  as  uncommon  as 
formerly  believed.  The  ulcer  is  single  and  characterized  by  marked  indu- 
ration. There  is  little  bleeding  or  discharge. 

(&)  Secondary  lues.  These  lesions  assume  the  form  of  broken-down 
papules.  The  ulcers  are  usually  multiple,  slightly  elevated,  and  covered  with 
yellowish  necrotic  material.  They  are  usually  associated  with  secondary 
lesions  elsewhere  on  the  body. 

(c)  Tertiary  gumma.  These  are  very  rare  and  may  simulate  cancer, 
particularly  if  there  has  been  much  necrosis  of  cervical  tissue.  The  ulcers 
in  this  condition  are  elliptical,  sharply  defined,  and  are  usually  covered  with 
necrotic  deposits.  A  routine  Wassermann,  done  on  all  patients,  will  save 
much  confusion. 

CONDYLOMA  OF  THE  CERVIX. — This  is  rare,  but  may  be  mistaken  for 
everting  epithelioma.  It  is  most  often  seen  in  pregnancy,  when  it  may 


CARCINOMA   OF   THE   UTERUS  213 

resemble  a  cock's  comb,  consisting  of. a  long  base  surmounted  by  many 
small,  flat,  epithelial  outgrowths.  It  may  be  white  or  reddish  in  color. 
There  is  no  induration.  On  microscopic  examination  the  benign  structure 
will  be  seen.  The  condyloma  is  a  distinct  papillary  outgrowth  from  the 
cervix  and  is  covered  by  normal  epithelium. 

DIPHTHERITIC  PATCHES. — These  are  very  rare,  yet  may  simulate  a 
sloughing  cervical  cancer.  There  is  usually  elevation  of  temperature  and 
other  systemic  disturbances  which  may  suffice  to  establish  the  nature  of  the 
trouble.  The  Klebs-Loeffler  bacillus  can  readily  be  isolated. 

SARCOMA  OF  THE  CERVIX. — This  is  an  unusual  condition  and  presents 
as  a  mass  of  polypoid  grapelike  structures,  which  are  easily  detached  from 
the  rapidly  growing  tumor.  They  may  be  very  difficult  to  eliminate  in  the 
diagnosis  without  microscopic  study.  Both  the  circumscribed  and  diffuse 
varieties  produce  enlargement,  hardening,  and  fixation  of  the  uterus. 

RETAINED  PORTIONS  OF  THE  PLACENTA. — Very  rarely  retained  portions 
of  the  placenta  which  lie  in  the  cervical  canal  after  incomplete  abortion  and 
are  associated  with  hemorrhage  or  infection,  and  the  consequent  necrosis, 
may  simulate  cancer.  There  should  be  little  difficulty,  however,  since  the 
history  and  elevation  of  temperature  should  suggest  the  true  condition. 

ENDOTHELIOMA  OF  THE  CERVIX. — This  is  an  extremely  rare  condition. 
Our  knowledge  concerning  it,  up  to  the  present  time,  is  based  only  on  a  few 
reported  cases.  The  differential  diagnosis  between  it  and  squamous  cell 
carcinoma  may  be  impossible  clinically,  and  may  present  the  greatest  dif- 
ficulties, even  on  histologic  examination. 

Prognosis. — The  prognosis  of  cancer  is  death  unless  the  condition 
has  been  removed  by  some  surgical  procedure.  There  are  no  reported 
cases  of  spontaneous  cure,  in  which  the  diagnosis  has  been  confirmed 
by  the  microscope,  which  .have  stood  without  recurrence  for  five  years. 
Cancer  may  undergo  spontaneous  cure  in  other  parts  of  the  body,  and 
Gaylord  and  Clowes  have  collected  14  instances,  yet  no  case  has  come 
to  their  consideration  which  was  of  the  cervix. 

The  average  duration  of  the  disease  from  the  onset  of  first  symp- 
toms to  death  is  from  fifteen  to  twenty  months,  yet  may  vary  widely 
because  of  many  factors.  Cancers  differ  markedly  in  malignancy,  and 
great  variations  occur  in  the  individual  resistance  of  the  patient.  The 
adenocarcinoma  of  the  cervix  is  usually  much  more  malignant  than 
the  squamous  cell  carcinoma.  Generally  speaking,  the  inverting  type 
of  growth  is  more  malignant  than  the  everting  variety,  yet  there  are 
great  variations  in  the  individual  cancers  of  the  same  general  classifi- 
cation. Thus,  there  is  a  very  malignant  form  of  everting  squamous 
cell  carcinoma  of  the  portio  which  gives  metastases  early  and  pro- 
gresses to  a  speedy  termination.  On  the  contrary,  there  is  a  very  slow- 
growing  inverting  form  of  adenocarcinoma  of  the  cervix.  Unfortu- 
nately, we  cannot  determine  the  malignancy  of  a  growth  by  its  his- 
tologic structure.  The  scirrhous  forms  are  usually  less  malignant  than 


214  PELVIC   NEOPLASMS 

the  medullary  growths  which  present  early  degenerative  changes. 
Cancers  which  are  composed  of  cells  of  irregular  size  and  form,  and 
which  present  much  evidence  of  rapid  cell  proliferation,  are  likely  to 
be  very  malignant.  We  have  already  called  attention  to  the  fact  that 
the  duration  of  the  disease  may  be  modified  by  local  conditions.  Cancer 
is  most  malignant  in  the  young,  and  the  pregnant,  and  shortly  after 
the  puerperium,  since  the  pelvis  is  usually  hypervascular  and  the 
lymphatic  structures  most  highly  developed.  It  is  of  longer  average 
duration  when  it  develops  after  the  menopause. 

Cancer  may,  however,  run  a  very  rapid  course.  Kiwisch.  reports 
one  case  which  progressed  to  death  in  five  weeks,  Martin  one  which 
lasted  for  nine  weeks,  and  Henry  Morris  one  of  four  months.  The 
diagnosis  in  these  cases  was  confirmed  by  the  microscope.  There  are 
comparatively  few  cases  in  which  the  disease  lasted  for  three  years  or 
more;  Roger  Williams  was  able  to  collect  a  number  which  formed 
16  per  cent  of  his  collected  cases.  Rarely  the  disease  may  last  for  a 
considerable  time  when  the  case  presents  partial  healing  due  to  the 
development  of  cicatricial  tissue  which  isolates  the  cancer  cells  and 
restrains  their  development.  Barker  has  reported  one  case  in  which 
the  duration  was  eleven  years.  Martin  quotes  a  case  of  cervical  car- 
cinoma which  was  seen  by  him  when  it  was  a  fairly  extensive  growth, 
and  which  remained  alive  at  the  time  of  his  report,  twenty-two  years 
later,  although  the  entire  vault  of  the  vagina  had  been  transformed  into 
a  fistulous  necrotic  ulcer. 


LITERATURE 

\ 

CLOWES,  BAESLECK  AND  GAYLORD.    J.  Am.  Ass.  1915.     165:968. 

CULLEN.     Cancer  of  the  Uterus.     1900. 

DUBLIN.    Am.  J.  Phys.  Anthr.     1920.     3:  175. 

FARR.    Am.  J.  M.  Sc.     1919.     157:  34. 

FLAISCHLEN.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1895.    32 :  347. 

GEBHARD.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1892.    24:  i. 

GREEN.     Edinb.  M.  J.     1915.     14,  15. 

HOFFMAN.    Mortality  of  Cancer  throughout  the  World.    American  Society 

for  Control  of  Cancer. 

KAUFMANN.     Jahresb.  d.  schles.  Gesellsch.  f.  vaterl.  Knit.     1894.     72:  52. 
KUNDRAT.    Arch.  f.  Gynak.     1903.    49:  366. 
LEVIN.     J.  Am.  M.  Ass.     1917.     69:  1068. 
OFFERGELD.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1908.    63:  217. 

Ztschr.  f.  Geburtsh.  u.  Gynak.     1909.    64:  i. 
RIBBERT.     Das  Karzinom  des  Menschen;  sein  Bau,  sein  Wachstum,  seine 

Entstehung.     Bonn,  1911. 
PEYTON-ROUS.    Johns  Hopkins  Hosp.  Bull.     1915.    26:146. 


CARCINOMA   OF   THE    UTERUS  215 

SAMPSON.    J.  Am.  M.  Ass.    1911.    56:101. 

SHIRLAW.     Practitioner.     1918.     100:  269. 

SLYE.     Journal  Cancer  Research.     1921.     6:  57. 

SCHOTTLAENDER-KERMAUNER.  Zur  Kenntnis  des  Uteruskarzinoms.  Ber- 
lin, 1912. 

TAUSSIG.     Surg.,  Gyn.  &  Obst.     1912.     15:147. 

THEILHABER.    Zentralbl.  f.  Gynak.     1911.     35:355. 

VON  ROSTHORN.  Festschrift  zur  Feier  des  fiinfzigjahren  Jubilaums  des 
Gesellschaft  fiir  Geburtshiilfe  und  Gynakologie.  Wien,  1894.  319. 

WERTHEIM.  Die  Erweiterte  Abdominale  Operation  bei  Carcinoma  Colli 
Uteri.  Berlin  und  Wein,  1911. 

WILLCOX.     J.  Cancer  Research.     1917.    2:  267. 

WILLIAMS,  ROGER.    Brit.  Gyn.  J.     1895-96.     n. 

ZELLER.     Ztschr.  f.  Geburtsh.  u.  Gynak.     1895.     11:56. 


CHAPTER  IX 

TREATMENT  OF  CANCER  OF  THE  CERVIX;   OPERATIONS;   PALLIATIVE 
TREATMENT;  RADIOTHERAPY 

Historical  sketch — Value  of  removing  pelvic  lymph  glands — Operations  for  cervical  cancer 
— Selection  of  cases  for  operation — Complications  and  centra-indications  to  operation 
— Operability — Choice  of  operation — Radical  abdominal  operation — Technic  of  Wert- 
heim's  operation — Drainage,  complications — After  treatment — Mackenrodt's  operation 
— Bumm's  operation — Paravaginal  operation— Schauta's  operation — Complications — 
Other  operations  for  cancer  of  the  cervix — Cautery  amputation — Werder's  cautery 
hysterectomy — Vaginal  hysterectomy — High  cervical  amputation — Palliative  treat- 
ment— General  methods — Acetone — Percy's  method  of  cauterization — Method  of 
calculating  operative  results — Results  of  radical  operation — Statistics — Of  radical 
operations — Statistics  of  non-radical  operative  treatment — Treatment  of  recurrences 
following  operation — Radio-therapy — Radium — Action  of  radium — Technic  of  appli- 
cation—Dosage— Screenage — Cross-fire — Complications  of  radium  treatment — Results 
of  radium  treatment — In  operable  growths — In  border-line  cases — In  inoperable  car- 
cinoma— In  recurrences — Operation  after  radium  treatment — Radium  preliminary  to 
operation. 


TREATMENT  OF  CANCER  OF  THE  CERVIX 

The  treatment  of  cancer  of  the  cervix  may  be  divided  according  to 
the  stage  of  the  disease,  into  three  sections:  (i)  the  earlier  stages,  in 
which  the  therapeutic  measures  are  designed  to  cure;  (2)  the  middle  or 
border-line  cases,  in  which  the  treatment  aims  to  alleviate  the  symp- 
toms, and  possibly  to  cure;  (3)  the  inoperable  or  terminal  stage,  in 
which  the  treatment  is  directed  only  toward  the  relief  of  suffering 
and  the  mitigation  of  the  most  distressing  symptoms. 

Historical  Sketch. — Until  comparatively  recent  times  when  the 
diagnosis  of  cancer  was  established,  the  condition  was  considered  hope- 
less. Palliative  measures  only  were  adopted  which  consisted  largely 
of  curetting  the  ulcer  and  in  cauterization.  Very  rarely,  serious  effort 
was  made  to  remove  the  growth.  As  early  as  1560,  Andreas  A.  Cruce, 
of  Granada,  performed  a  hysterectomy  with  a  cautery  iron  upon  a 
carcinoma  embodied  in  a  prolapsed  uterus.  This  method  of  treatment 
was  followed  by  others,  so  that  in  1,600  cases  von  Schenk  was  able  to 
collect  26  in  which  there  had  been  partial  or  complete  removal  of  the 
uterus.  In  1801,  Osiander  taught  that  amputation  of  the  cervix 
should  be  performed  as  a  curative  measure.  In  1813,  Langenbeck  per- 
formed a  vaginal  hysterectomy  by  enucleating  a  carcinomatous  pro- 

216 


TREATMENT    OF    CANCER    OF    THE    CERVIX 


217 


lapsed  uterus  without  opening  the  peritoneum.  Sauter,  in  1821, 
divided  the  broad  ligaments  and  ligated  the  uterine  vessels  with  mass  , 
ligatures,  and  performed  vaginal  hysterectomy.  With  the  advent  of 
anesthetics,  many  surgeons  attempted  similar  operations.  The  first 
advance  in  the  principles  of  treatment  beyond  this  point  was  advo- 
cated by  W.  A.  Freund,  who  called  attention  to  the  fact  that  there  was 
a  definite  advantage  obtained  by  a  laparotomy,  inasmuch  as  the  upper 
limits  of  the  disease  could  best  be  appreciated.  To  facilitate  exposure, 
he  made  use  of  the  pelvic  elevation  which  was  subsequently  popularized 
by  Trendelenburg,  and  which  is  now  commonly  called  the  Trendelen- 
burg  position.  By  this  method  he  removed  a  carcinomatous  uterus  by 
abdominal  section  on  January  30,  1878,  and  six  months  later  he  was 
able  to  report  5  similar  cases  with  3  recoveries.  Twenty-six  years 
later  he  presented  one  of  these  cases  at  a  gynecologic  congress  in 
Breslau  and  demonstrated  the  specimen  which  had  been  diagnosed 
by  Cohnheim  at  the  time  of  operation.  There  had  been  no  recurrence 
up  to  that  time,  although  his  first  patient  died  of  recurrence  one  year 
after  operation.  Yet  the  immediate  mortality  attending  Freund's 
operation  in  the  hands  of  others  was  so  high  that  it  was  not  widely 
adopted.  Ahlfeld,  in  1880,  found  that  the  mortality  of  all  recorded 
cases  was  73  per  cent,  and  Gusserow  later  collected  148  cases  with  a 
mortality  of  71  per  cent.  The  fact  that  freedom  from  recurrence  was 
not  frequent  proved  the  greatest  blow  to  the  method,  as  was 
demonstrated  by  Rokitansky,  who,  in  1882,  collected  95  cases  that  had 
endured  this  operation  with  an  immediate  mortality  of  65  cases.  Of 
the  remaining  30,  there  was  not  one  that  escaped  a  recurrence.  The 
consequence  was  that  operators  turned  to  the  vaginal  operation  which 
was  then  being  developed  by  Czerny  in  Heidelberg  after  the  method 
first  proposed  by  Sauter.  Czerny's  first  case  was  operated  success- 
fully on  August  12,  1878.  The  following  table  shows  the  primary 
results  from  vaginal  hysterectomy  from  the  years  1880  to  1897: 


Authority 

Year 

Cases 

Per  cent 
mortality 

Heidler  

1880 

52 

36.5 

Olshausen              

1881 

41 

2O 

Hahn                    

1882 

48 

29.  I 

Czerny  .  .            

1882 

81 

32 

Saenger            .'  

1883 

133 

28.6 

Engstroem  

1883 

157 

29 

Kaltenbach  .        

1885 

2<?7 

23 

Gusserow  ...        

1885 

2^3 

23  .  1 

Sarah  Post          

1887 

722 

24 

Schauta           

1891 

724 

ii.  6 

Hofmeier  .        

1892 

749 

9.  2 

Hirschmann                

189^ 

1241 

8.8 

\Visselinck  

1897 

1740 

8 

218  PELVIC  NEOPLASMS 

With  the  improvement  in  operative  technic,  others  turned  their 
attention  to  the  development  of  operations  after  abdominal  exposure. 
In  1881,  Bardenheuer  introduced  vaginal  drainage  which,  in  a  short 
time,  reduced  the  primary  mortality'of  abdominal  hysterectomy  from 
70  per  cent  to  33  per  cent.  In  the  same  year,  Kolaczeck,  Reuss,  and 
later  Rydygier,  called  attention  to  the  evil  effects  resulting  from  mass 
ligatures.  Stimson,  in  1889,  advocated  ligation  of  blood  vessels  after 
their  isolation.  Shortly  after,  Goffe,  Polk,  and  Baer  took  advantage 
of  Stimson's  procedure,  improved  methods  of  peritonealization  and 
emphasized  the  value  of  Bardenheuer's  vaginal  drainage  and  the  neces- 
sity for  the  elevated  pelvic  position  which  was  now  called  the  Tren- 
delenburg  position.  This  resulted  in  a  great  reduction  in  the  mortality 
attending  abdominal  hysterectomy,  which  nearly  all  agreed  was  the 
only  method  which  permitted  a  proper  inspection  of  the  growth. 

Ries,  in  1895,  proposed  an  operation  which  he  had  perfected  upon 
the  cadaver  which  aimed  to  remove  the  uterus,  parametrium,  upper 
vagina  and  pelvic  lymph  tracts  in  one  piece.  He  emphasized  especially  the 
need  of  removing  the  pelvic  lymph  glands.  In  the  same  year,  Clarke  and 
Rumpf  proposed  and  practiced  similar  operations,  and  emphasized  the  fact 
that  it  was  necessary  to  isolate  the  ureters  to  obtain  a  proper  removal  of  the 
parametrium.  Numerous  reports  now  appeared  in  the  literature  call- 
ing attention  to  the  lack  of  cures  after  the  older  type  of  operation.  They 
showed  that  metastases  were  far  more  common  than  had  been  believed  and 
undoubtedly  were  responsible  for  the  tremendous  percentage  of  recur- 
rences. Mackenrodt  insisted  upon  the  fact  that  the  surgical  removal 
of  uterine  cancer  was  not  really  started  until  the  extirpation  of  the 
parametria  began.  Werder,  in  1898,  developed  the  operation  which 
was  subsequently  proposed  independently  and  popularized  by  Wert- 
heim.  Sampson,  and  others,  developed  operations  which  were  even 
more  radical,  yet  which  almost  without  exception  have  been  abandoned 
because  experience  has  shown  that  they  were  too  radical  to  be  prac- 
tical. Radical  operations  have  been  adopted  very  slowly,  because  the 
great  majority  of  surgeons  cannot  bring  themselves  readily  to  perform 
operations  which  carry  a  high  mortality. 

The  modern  radical  operation  has  been  popularized  largely  through 
the  work  and  writings  of  Wertheim.  A  painstaking  study  of  the 
method  of  growth  of  uterine  cancer  worked  out  in  many  laboratories, 
as  well  as  a  careful  consideration  of  the  results  following  ordinary 
hysterectomy,  have  shown  that  a  surgical  cure  can  result  only  after  all 
the  ramifications  of  the  growth  have  been  removed.  Laboratory 
workers  have  proved  the  uncertainty  of  clinical  examinations;  thus 
they  have  shown  that  a  soft  parametrium  may  be  cancerous  and  that 
an  infiltrated  one  may  be  free  from  cancer  cells;  also  that  carcinoma- 
tous  lymph  glands  may  be  of  normal  size.  Thus,  Wertheim,  in  1907, 
proved  that,  in  22.5  per  cent  of  his  cases,  the  parametria  were  soft  on 


TREATMENT  OF  CANCER  OF  THE  CERVIX         219 

clinical  examination,  yet  were  found  by  microscopic  examination  to 
contain  cancerous  deposits,  and  that  carcinoma  could  not  be  demon- 
strated in  14  per  cent  of  parametria  which  were  thickened  and  infil- 
trated. The  parametria  and  lymphatic  glands  were  involved  together 
in  20  per  cent  of  his  cases.  Kundrat,  in  1903,  found  that  the  para- 
metria were  free,  but  there  was  lymphatic  involvement  in  8  of  his  80 
cases.  Cancer  was  found  to  be  present  in  the  parametria  without 
lymph  gland  involvement  in  27.5  per  cent  of  cases.  Kermauner  and 
Lameris  found  the  parametria  were  carcinomatous  in  72  per  cent  of 
von  Rosthorn's  33  cases  studied  in  Heidelberg.  Schauta,  in  96  cases, 
found  that  one  or  both  parametria  were  involved  in  two-thirds  of  his 
cases.  Cullen  reported  that  the  disease  had  invaded  the  broad  ligament 
in  nearly  every  case  of  adenocarcinoma  in  Kelly's  clinic.  Kroemer 
proved  the  existence  of  carcinomatous  invasion  of  the  parametria  in 
all  of  his  cases.  These,  and  similar  studies,  indicated  the  futility  of 
operations  limited  to  the  removal  of  the  uterus,  since  it  was  found  that 
the  growth  had  extended  beyond  the  uterus  in  60  per  cent  of  cases 
which  were  deemed  operable  and  that  the  actual  condition  of  the  para- 
metria and  glands  cannot  be  determined  by  clinical  examination.  All, 
therefore,  agree  that  all  possible  tissue  in  the  neighborhood  of  the 
uterus  should  be  removed.  The  necessity  of  excising  the  upper  vagina 
together  with  the  parametria  is  demonstrated  by  finding-  that  four- 
fifths  of  the  recurrences  following  ordinary  hysterectomy  have  devel- 
oped in  the  vaginal  scar.  Brunet  found  cancer  in  the  upper  vagina  in 
42.6  per  cent  of  47  of  Mackenrodt's  cases.  With  complete  agreement 
as  to  the  necessity  of  removing  in  one  piece  the  uterus,  parametria,  and 
upper  vagina,  the  discussion  has  become  narrowed  to  the  value  of 
removing  the  lymphatic  glands. 

The  Question  of  Removing  Pelvic  Lymph  Glands. — Theoretically, 
the  ideal  surgical  removal  of  a  carcinomatous  cervix  should  include  the 
systematic  resection  of  the  entire  cancerous  areas  and  their  avenues 
of  drainage  in  one  piece  as  advocated  by  Ries.  Lymph  glands  which 
are  cancerous  are  as  dangerous  as  the  original  tumor.  They  are 
admittedly  involved  in  from  30  to  50  per  cent  of  early  cases  and  prob- 
ably in  a  larger  per  cent  of  the  cases  considered  operable  in  America. 
Unfortunately,  moreover,  there  is  no  clinical  method  of  determining 
what  cases  present  glandular  involvement  and  the  extent  to  which  it 
has  occurred.  Yet  it  has  been  abundantly  proved  that  no  operation  of 
any  type  can  cure  advanced  carcinoma.  Therefore,  it  is  natural  that 
there  should  be  considerable  discussion  as  to  the  value  of  removing  the 
lymph  glands,  particularly  if  the  attempt  adds  considerably  to  the  mor- 
tality and  proves  ineffectual  in  the  end.  The  evidence  shows  that  the 
disease  is  hopeless  from  the  surgical  standpoint  when  it  has  extended 
beyond  the  parametria.  There  are  some  undoubted  instances  in  which 
the  patients  have  survived  a  five-year  period  of  cure  after  removal  of 


220  PELVIC   NEOPLASMS 

carcinomatous  lymph  glands,  but  they  are  few.  Many  investigators 
(Olshausen,  Hofmeier,  Ott,  Richelot,  and  others)  insist  that  it  is 
impossible  to  remove  all  the  lymph  glands  at  the  operation.  Post- 
mortem records  have  clearly  shown  that  while  carcinomatous  lymph 
glands  have  been  removed  during  operation,  many  others  have  been 
overlooked.  Staude  believed  that  extensive  removal  of  the  lymphatics 
is  not  possible  upon  the  living  subject,  and  demonstrated  in  4  post- 
mortem cases  that  a  resection  of  a  portion  of  the  mesentery  would  have 
been  necessary  in  order  to  remove  one  single  carcinomatous  gland. 
It  has  also  been  claimed  that  posterior  to  the  hypogastric  artery  there 
is  a  small  gland  which  is  frequently  involved  as  demonstrated  by  post- 
mortem findings,  but  which,  on  account  of  its  hidden  position,  cannot 
be  palpated  during  operation. 

The  work  of  Schauta  is  often  quoted  by  those  who  do  not  believe 
in  the  routine  removal- of  the  glands.  He  collected  the  glands  from  60 
post-mortem  cases.  They  numbered  1,182  and  were  cut  into  160,000 
microscopical  sections.  For  purposes  of  study  they  were  divided  into 
two  groups,  those  accessible  at  operation  (iliac  and  sacral)r  and  those 
inaccessible  (lumbar,  celiac,  superficial  and  deep  inguinal).  Both 
divisions  were  found  involved  in  35  per  cent  of  cases.  In  another  8.3 
per  cent  there  was  an  involvement  of  the  inaccessible  lymph  glands 
without  involvement  of  the  accessible  group,  so  that  removal  of  the 
accessible  glands  would  have  been  valueless  in  43.3  per  cent  of  the 
cases,  because  the  other  set  was  also  involved.  In  another  43.3  per 
cent  of  cases,  both  sets  were  free  and  in  13.3  per  cent  the  accessible 
group  were  involved,  although  the  inaccessible  group  were  not  invaded. 
Schauta  concludes,  therefore,  that  removal  of  the  glands  was  indicated 
only  in  the  13.3  per  cent  because,  in  the  43.3  per  cent  it  would  have 
been  unnecessary  and  in  the  other  43.3  per  cent  group  useless. 

Both  Baisch  and  Wertheim  have  shown  defects  in  Schauta's  con- 
clusions. Out  of  the  60  cases  50  were  inoperable  and  should  be  ruled 
out  of  the  discussion  because  only  operable  cases  were  being  studied. 
Of  the  10  operable  cases,  therefore,  that  remained,  8  were  free  from 
glandular  involvement  while  in  the  other  2,  both  the  accessible  and 
inaccessible  nodes  were  involved.  These  were  too  few  cases  to  draw 
any  conclusions.  On  the  other  hand,  Baisch  was  unable  to  find  a  case 
in  which  both  the  upper  and  lower  sets  of  nodes  were  involved  in  his 
study  of  52  Cases  of  cervical  carcinoma.  Similar  findings  were  ob- 
tained by  Winter,  in  45  cases,  and  Oehlecker,  in  7  cases.  Unfor- 
tunately, Schauta  does  not  mention  the  site  of  the  tumor  and  Baisch 
suggests  that  probably  carcinoma  of  the  body  was  included  in  his  series. 
In  von  Rosthorn's  cases,  the  lumbar  nodes  were  found  involved  in  9 
per  cent.  Although  Schauta's  conclusions  are  not  supported  by  subse- 
quent investigations,  his  work  is  of  interest,  inasmuch  as  it  showed  that 
in  only  43.3  per  cent  of  his  cases  were  glands  involved. 

Many  have  claimed  that  the  lymph  channels  should  be  removed 


TREATMENT  OF  CANCER  OF  THE  CERVIX         221 

with  the  affected  glands  or  the  purpose  of  the  operation  is  defeated. 
Yet  it  is  true  that  if  the  lymphatics  are  filled  with  cancer  cells,  opera- 
tion is  of  no  value.  Sampson's  work  suggests  that  when  cancer  first 
invades  the  lymphatics,  the  growth  extends  as  solid  columns  for  a  short 
distance,  and  that  the  glands  become  involved  by  small  groups  of  can- 
cer cells,  which  have  broken  away  from  the  carcinomatous  columns, 
and  have  been  carried  along  the  lymphatic  currents  to  the  hilum  of 
the  glands.  Handley  also  demonstrated  continuity  of  the  cancerous 
growth  from  the  primary  tumor  into  the  regional  lymphatic  channels, 
spreading  centrifugally  by  direct  extension,  and  largely  independent 
of  any  washing  away  of  cells.  Cancer  cells  in  the  lymph  tract  have  also 
been  found  by  Kermauner,  Veit,  Schauta,  and  others.  Their  work 
emphasizes  the  importance  of  removing  as  much  as  is  possible  of  the 
tissue  lying  between  the  primary  tumor  and  the  lymphatic  metastases. 
Unfortunately,  the  removal  of  the  glands  may  be  the  most  formidable 
part  of  the  operation,  since  they  may  be  firmly  adherent  to  the  vessels 
on  which  they  normally  lie  and,  in  efforts  to  remove  them,  the  thin- 
walled  veins  may  be  torn  through.  Fatalities  from  this  complication 
have  occurred  so  frequently  that  the  removal  of  the  glands  has  been 
discontinued  by  most  surgeons.  Wertheim  insists  that  removal  of  the 
glands  is  not  as  important  as  the  removal  of  the  parametria.  Weibel, 
in  1914,  stated  that  25  per  cent  of  Wertheim's  cases  were  found  to  have 
involvement  of  glands  and  that  all  of  them  eventually  succumbed  to  the 
disease.  We  have  already  alluded  to  Schauta's  findings.  Peterson 
removed  29  pelvic  glands  but  only  5  were  involved.  Hofmeier,  in  1911, 
states  that  the  glands  were  enlarged  in  46  of  90  cases.  Only  18  (33.3 
per  cent)  were  carcinomatous.  In  no  case  in  which  the  glands  were 
involved  was  a  lasting  cure  obtained.  Ries  and  Bumm  are  the  cham- 
pions of  the  routine  removal  of  glands  in  which  stand  they  remain 
practically  alone.  They  call  attention  to  the  fact  that  cancer  always 
kills  unless  removed  and  that  it  is  worth  while  to  risk  the  serious  pro- 
cedure with  a  hope  of  curing  occasional  cases.  Sampson's  work  shows 
that  if  the  lymph  glands  have  not  been  removed  in  the  operable  cases, 
cancer  has  been  left  behind  in  at  least  one-third  and  in  possibly  over 
half  the  cases.  While  it  is  impossible  to  remove  at  operation  all  the 
lymph  glands  which  may  be  involved,  we  must  realize  that  the  more 
thorough  and  complete  trje  operation,  the  greater  the  chance  of  curing 
the  patient.  Occasionally,  cancer  is  arrested  by  the  lymph  glands. 
For  these  reasons,  we  believe  that  we  should  do  the  most  thorough 
operation  that  each  individual  patient  will  stand. 

Operations  for  Cervical  Cancer. — As  we  have  already  indicated,  the 
limit  to  which  surgical  operations  may  be  extended  has  been  fully 
reached.  All  agree  that  no  form  of  operation  may  hope  to  cure  late 
cancer,  and  that  radical  operation  should  be  employed  only  in  early 
cases.  The  trend  of  opinion  is  that  all  others  should  be  radiated. 
There  are  few  dissenting  voices  to  the  belief  that  ordinary  vaginal  or 


222  PELVIC   NEOPLASMS 

simple  abdominal  hysterectomy  should  never  be  done.  The  surgical 
principles  for  the  treatment  of  cancer  of  the  cervix  are  identical  with 
those  which  obtain  for  operation  of  cancerous  organs  elsewhere  in  the 
body.  The  fundamental  principle  should  be  block  excision  of  the  entire 
cancer  field  in  one  piece,  including  the  area  of  lymphatic  distribution 
and  drainage.  Practical  considerations,  however,  especially  those  of 
primary  mortality,  permit  one  to  limit  the  operation  to  wide  removal  of 
uterus,  tubes  and  ovaries,  broad  ligament  and  parametrium,  vagina 
and  paracolpium,  in  one  piece.  Practically,  however,  no  operation  can 
ever  be  devised  for  the  treatment  of  cervical  carcinoma  which  will  be 
ideal.  From  the  very  nature  of  things,  considerable  trauma  must 
attend  any  operation  which  seeks  to  remove  tissues  from  the  depths  of 
the  pelvis,  since  they  never  can  be  brought  to  the  surface  of  the  wound 
without  much  traction.  The  radical  operation  is  attended  with  con- 
siderable primary  mortality,  for  which  reason  many  still  perform  lim- 
ited operations,  thus  losing  for  the  patient  a  rational  chance  of  per- 
manent cure.  Some  have  decried  the  radical  operation  because  it  is  so 
difficult  technically  that  it  should  not  be  performed  by  the  majority  of 
men  in  active  surgical  practice.  We  cannot  believe  that  this  is  a  valid 
objection.  There  is  abundant  proof  that  the  operation  cures  when 
more  limited  procedures  fail.  It  is  our  firm  belief  that  the  situation  will 
not  be  improved  by  simple  ablation  of  the  uterus  through  the  vagina, 
or  by  simple  abdominal  hysterectomy,  as  is  now  done  in  the  great  mass 
of  cases  throughout  the  country.  Both  the  laity  and  the  profession 
should  be  educated  to  know  that  cancer  invariably  kills  unless  it  is 
removed  completely  and  that  nothing  is  gained  for  the  patient  by  an 
incomplete  removal. 

Selection  of  Cases  for  Operation. — In  order  to  obtain  good  results, 
cases  must  be  selected  carefully  for  operation.  The  vagina  should 
always  be  carefully  examined  to  detect  cancerous  nodules.  These  are 
recognized  without  difficulty  when  they  are  elevated  above  the  sur- 
rounding mucosa,  but,  if  they  exist  as  flattened  plaques,  they  may 
be  easily  overlooked.  Next  the  broad  ligament  should  be  examined  to 
determine  the  presence  of  induration,  yet  it  is  important  to  remember 
that  a  soft  parametrium  may  contain  cancer  cells,  and  that  parametric 
thickening  and  induration  may  be  due  only  to  an  inflammatory  change. 
We  should  constantly  bear  in  mind  that  the  condition  of  the  para- 
metrium does  not  always  indicate  the  extent  to  which  the  cancer  has 
spread,  yet  it  is  apparent  that  a  growth  which  has  left  a  large  ulcer  is 
likely  to  have  involved  the  parametrium.  The  uterosacral  ligaments 
should  be  carefully  palpated.  This  is  best  done  through  the  rectum. 
The  presence  of  enlarged  glands  along  the  sacrum  should  be  carefully 
sought  for.  Beadlike  irregularities  along  the  course  of  these  ligaments 
strongly  suggests  carcinomatous  invasion,  yet  induration  may  exist 
here  from  a  previous  endocervicitis  associated  with  old  lacerations. 
The  condition  of  the  local  uterine  growth  must  be  taken  into  considera- 


TREATMENT  OF  CANCER  OF  THE  CERVIX        223 

tion  in  estimating  the  chance  of  parametric  invasion.  If  the  tissues 
about  the  cervix  are  normally  soft,  the  cancer  presumably  is  still  local. 
On  the  other  hand,  if  there  is  an  extensive  local  growth  with  indura- 
tions extending  along  the  pelvic  walls  on  one  or  both  sides,  sufficient 
to  fix  the  uterus,  there  is  every  reason  to  believe  that  the  parametria 
are  involved  and  the  case  is  at  least  at  the  border  line  of  operability. 
The  majority  of  men  believe  that  this  type  of  growth  is  best  treated 
by  radium.  Bumm  stands  almost  alone  in  recommending  operation. 
The  general  condition  of  the  patient  and  her  past  history  may  aid 
in  arriving  at  an  opinion  as  to  the  nature  of  the  induration,  yet  the  local 
growth  is  of  primary  importance.  When  the  disease  has  spread  down 
to  the  vagina,  or  has  involved  the  bladder  or  rectum,  either  with  or 
without  the  formation  of  fistulae,  the  disease  is  quite  hopeless.  Cysto- 
scopic  examination  occasionally  aids  us  in  determining  whether  the 
bladder  is  involved.  Pale,  edematous  patches  of  the  vesical  mucous 
membrane,  especially  in  the  region  of  the  trigonum,  usually  indicate 
that  the  wall  of  the  bladder  has  become  infiltrated  by  the  cancer. 
Their  presence  does  not  absolutely  contra-indicate  attempt  for  radical 
operation,  although  it  often  causes  failures.  When  the  vesical  wall 
is  infiltrated  and  contains  yellow-white  circumscribed  nodules,  the 
viscus  is  definitely  involved,  and  the  operation  should  not  be  under- 
taken, since  experience  has  absolutely  demonstrated  that  it  will  not 
accomplish  cure.  Occasionally,  the  bladder  mucosa  which  overlies  the 
cervix  is  pale  and  wrinkled,  and  suggests  infiltration  of  the  underlying 
musculature.  The  greatest  care  is  necessary  in  separating  the  bladder 
from  the  uterus  at  operation  in  this  type  of  case.  Fromme,  in  1908,  was 
unable  to  detect  any  changes  in  the  interior  of  the  bladder  in  65  of  no 
cases  of  carcinoma  of  the  cervix,  and  in  all  of  them  he  was  able  to 
effect  a  separation  of  the  bladder  at  operation.  He  found  vesical 
edema  in  15  of  his  cases,  and  regarded  it  as  an  evidence  of  bladder 
involvement,  since  the  bladder  could  be  freed  from  the  uterus  and 
cervix  only  with  much  difficulty.  Cruet  reviewed  the  report  of  500 
cystoscopic  examinations  made  on  cancer  of  the  cervix.  As  a  result  of 
this  investigation,  he  concluded  that  simple  bulging  of  the  bladder  wall 
was  not  of  diagnostic  significance,  but  when  the  floor  is  thrown  up  into 
deep  folds  with  intervening  valleys,  that  there  are  adhesions  between 
the  bladder  and  the  cervix.  While  these  do  not  constitute  an  absolute 
centra-indication  to  surgical  procedure,  they  limit  the  chance  of  cure. 
Such  cases,  we  believe,  are  better  treated  with  radium.  Cases  which 
present  edema  of  the  bladder  wall  must  be  regarded  as  inoperable. 
Before  the  advent  of  radium  into  the  therapeutic  field,  there  was  not 
complete  agreement  among  various  authorities  as  to  other  points 
which  render  the  case  inoperable.  The  ureteral  orifices  may  be  pushed 
to  one  side,  or  may  be  diffusedly  red  with  edema,  without  contra-indi- 
cating operation,  although  it  indicates  a  border-line  condition.  When 
the  ureteral  orifice  is  enlarged  and  flattened,  and  especially  when  it 


PELVIC  NEOPLASMS 

protrudes  as  an  edematous  area  into  the  bladder,  the  condition  is 
inoperable  because  of  bladder  involvement.  Some  hint  as  to  the 
involvement  of  the  bladder  wall  may  be  given  by  study  of  the  urine 
spurting  from  the  ureteral  orifice.  The  interval  between  the  spurts  is 
longer  and  the  jets  appear  more  forcible  on  the  involved  side. 

When  a  case  appears  border  line,  operation  is  justified  in  the 
absence  of  radium.  Yet  it  must  be  of  an  exploratory  nature  until  the 
surgeon  is  sure  that  there  are  no  metastases  which  contra-indicate  it. 
The  under  margin  of  the  liver,  especially  near  the  gall-bladder,  should 
be  inspected,  the  vault  of  the  diaphragm  palpated  for  peritoneal 
metastases,  the  pelvic  glands  should  be  carefully  palpated,  the  broad 
ligaments  minutely  inspected  and  the  lower  uterus  viewed  with  the  idea 
of  determining  whether  the  growth  has  involved  the  bladder  wall. 

Complications.— Various  conditions  may  be  present,  some  of  which 
absolutely  contra-indicate  operation.  Among  these  may  be  mentioned 
serious  heart  disease,  nephritis,  pyelonephritis,  diabetes,  tuberculosis 
and  other  systemic  diseases.  Even  though  the  local  condition  appears 
operable,  such  cases  are  far  better  treated  with  radium. 

There  are  a  number  of  other  conditions  which  merely  complicate 
the  operation.  Chief  of  these  is  pelvic  inflammatory,  which  occurs  so 
frequently  as  almost  to  constitute  the  rule.  Not  infrequently,  the 
pelvic  inflammatory  disease  may  be  so  extensive  that  in  itself  it  con- 
stitutes a  serious  condition.  Such  cases  cannot  be  treated  with  radium. 

Occasionally  carcinoma  may  arise  in  a  double  uterus.  Valentine  and 
Buist  have  collected  5  cases  in  which  carcinoma  was  present  in  a  double 
uterus  with  a  double  vagina,  4  of  which  had  a  cervical  cancer  and  the 
other  a  cervical  cancer  and  a  cancer  of  the  uterine  body.  Rossa 
describes  a  case  of  a  multiparous  woman  of  thirty-eight,  who  had  a 
bicornuate  uterus  with  a  cancerous  cervix  which  had  caused  atresia  of 
the  vagina  and  consequent  pyometra. 

Fibroids  may  be  present  with  cervical  carcinoma,  although  the  associa- 
tion is  not  as  frequent  as  in  cancers  of  the  fundus.  Kerr  found  only 
one  cancer  of  the  cervix  in  200  abdominal  hysterectomies  for  fibroids, 
although  he.  found  6  cases  of  cancer  of  the  uterine  fundus  in  the  same 
series.  The  relative  infrequency  of  cervical  cancers  in  fibroid  uteri  is 
all  the  more  striking,  since  cervical  cancers  are  from  fifteen  to  twenty 
times  more  common  than  cancers  of  the  uterine  body.  Others  state 
that  cervical  cancers  occur  with  fibroids  in  less  than  5  per  cent  of  cases, 
whereas  cancers  of  the  uterine  body  are  found  in  nearly  30  per  cent. 
Some,  as  Eden  and  Lockyer,  explain  this  variation  on  the  ground  that 
cancers  of  the  fundus  occur  on  the  average  in  older  women  than  do 
cancers  of  the  cervix.  In  this  connection,  the  statistics  of  Wertheim 
are  of  interest  in  that  6  per  cent  of  his  500  cases  occurred  in  women  of 
thirty  years  and  under  and  55  per  cent  occurred  in  women  of  forty-five 
years  and  less. 


TREATMENT   OF    CANCER   OF   THE    CERVIX 


225 


Tuberculosis  of  the  uterus  is  sometimes  observed  as  a  complication  of 
cervical  cancer.  Schottlaender,  and  Cullen,  each  have  observed  a  num- 
ber of  cases  in  their  own  series.  Delval  and  de  Halluin  have  added 
others  to  the  list. 

Pyomctra  often  complicates  the  operation,  even  in  operable  growths, 
so  frequently  in  fact  that  large  tenacula  may  not  be  safely  used  to 
elevate  the  fundus  during  operation.  Atresia  of  the  cervix  is  respon- 
sible for  the  greater  number  of  cases.  The  fluid  may  be  clear  and 
serous,  may  contain  pus,  or  may  be  bloodstained.  It  is  malodorous., 
often  extremely  fetid,  and  varies  in  quantity  from  a  few  drams  to  a  pint 
or  even  more.  Stein,  in  1910,  found  this  condition  most  frequent  in 
women  in  advanced  life,  since  it  usually  occurs  in  an  organ  which  has 
undergone  atrophy.  Walter  Tate  noted  it  3  times  in  28  cases,  and 
Biirkel  found  it  17  times  in  273  cases,  or  6.2  per  cent.  Many  cases  pre- 
sent no  symptoms,  although  it  is  quite  possible  that  the  condition  is 
overshadowed  by  pain  resulting  from  parametric  infiltration.  The 
majority,  however,  complain  of  pain,  either  alone  or  in  association  with 
a  purulent  discharge.  As  a  rule,  there  is  no  temperature  reaction,  nor 
general  symptoms. 

Pregnancy  in  association  with  cervical  carcinoma  constitutes  a  very 
grave  condition.  Fortunately,  it  is  rare,  although  it  is  rather  surprising 
that  it  is  not  more  often  seen,  since  cervical  carcinomata  were  noted  29 
times  in  women  under  thirty  years  in  Wertheim's  series  of  500  cases. 
The  disease  progresses  most  rapidly  because  the  congestion  of  the 
pelvic  tissues  and  the  marked  development  of  lymphatics  favors  early 
extension. 

Operability. — The  percentage  of  operability  for  a  number  of  Euro- 
pean and  American  surgeons  is  given  below.  In  studying  this 
table,  we  should  bear  in  mind  that,  in  the  future,  the  operability 
undoubtedly  will  be  reduced,  since  only  early  and  local  growths  will  be 
selected  for  operation.  Others  will  be  treated  with  radium. 

The  relation  of  the  operability  and  primary  mortality  is  shown  by 
the  following  table : 


Operator 

Percentage 
operability 

Percentage  primary 
mortality 

Teannel      .  .      .        

30 

•zz 

von  Rosthorn  

36 

136 

Doederlein 

48 

14.    3 

Klein  .    .                                              

4O 

12    8 

Reinecke  .  .      .    .            .                

AI 

21 

Polosson    

56 

18  7 

Wertheim  

So 

18 

Franz  

81 

19.28 

Bumm  

9° 

20 

Mackenrodt     

92 

10    2 

226  PELVIC  NEOPLASMS 

Graves,  in  1921,  emphasizes  the  fact  that,  in  the  past,  operability  has 
meant  that  the  surgeon  could  remove  the  growth,  whereas  in  the 
future  the  term  "operability"  will  be  restricted  to  cases  where  the 
growth  may  be  removed  with  hope  of  cure. 

Choice  of  Operation. — There  is  a  very  general  opinion  that  the 
abdominal  operation  is  preferable  to  that  done  through  the  vagina, 
whether  the  glands  are  to  be  removed  or  not,  since  the  best  exposure  is 
gained  by  laparotomy.  Schauta,  and  Staude,  on  the  other  hand,  claim 
that  when  the  paravaginal  incision  is  used  the  vagina,  rectum,  and 
bladder  are  more  accessible  than  by  the  abdominal  method.  Certainly, 
the  best  exposure  is  obtained  for  the  vaginal  and  parametric  removals. 
Yet  there  have  been  a  number  of  cases  reported  in  which  carcinoma 
was  implanted  in  the  vaginal  wound.  Jayle,  in  1909,  reported  severe 
disturbances  from  the  vaginal  cicatrix  of  the  paravaginal  incision. 
Reports,  moreover,  are  indicating  that  the  ultimate  results  are  not  as 
good  as  those  of  the  abdominal  route.  Certain  it  is  that  the  para- 
vaginal operation  is  one  that  may  not  be  successfully  undertaken  by  a 
surgeon  who  has  not  carefully  developed  this  trying  technic.  Macken- 
rodt,  and  others,  believe  that  the  paravaginal  operation  is  more  com- 
plicated and  dangerous  than  the  abdominal  one. 

Undoubtedly,  both  types  of  operation  have  thtir  advantages  for 
one  who  is  conversant  with  the  technic.  Now  that  radium  has  become 
the  accepted  treatment  for  all  except  early  and  clearly  localized 
growths,  it  may  be  that  revision  of  our  older  ideas  concerning  the 
advantages  and  disadvantages  of  each  type  of  operation  is  necessary. 
In  choosing  between  the  paravaginal  and  abdominal  operation,  it  is 
important  to  remember  that,  if  the  glands  are  involved,  the  prognosis 
is  very  poor.  Postoperative  shock  is  not  as  common  after  the  para- 
vaginal operation  as  following  laparotomy,  a  point  worth  remember- 
ing, if  the  case  is  very  fat  so  that  exposure  would  be  difficult  through 
an  abdominal  incision.  Accidental  injuries  are  just  as  frequent  in  both 
types  of  operation.  Injury  to  the  ureter  may  be  better  treated  from 
above,  although  unfortunately  such  injury  is  seldom  recognized  until 
the  development  of  complications.  With  the  passing  of  Schauta,  the 
paravaginal  operation  has  lost  its  great  exponent. 


RADICAL   ABDOMINAL   OPERATIONS 

At  the  present  time  there  are  two  general  types  of  operations:  one 
in  which  the  surgical  measures  are  restricted  to  the  removal  of  the 
uterus,  adnexa,  parametrium,  and  the  upper  vagina;  the  other  is  more 
truly  radical,  in  that  it  attempts  to  remove  all  the  tissues  in  the  pelvis 
which  may  be  involved  in  the  growth  of  the  disease.  The  first  type  is 
represented  by  the  operation  which  has  been  popularized  by  Wert- 


TREATMENT    OF    CANCER    OF    THE    CERVIX  227 

heim ;  while  the  other  is  exemplified  in  the  operations  of  Ries,  Macken- 
rodt,  and  Bumm. 

The  Wertheim  Operation. — This  operation  is  essentially  that  of 
Werder,  and  differs  from  it  only  in  a  few  details  of  technic.  It  merits 
the  name  Wertheim,  because  Werder  has  abandoned  the  operation, 
and  Wertheim,  by  his  persistent  work  for  twenty  years,  has  done  much 
to  put  the  surgical  treatment  of  carcinoma  on  a  sound  basis.  The 
operation  differs  from  the  older  methods  of  Ries,  Strumpf,  and  Clark, 
in  that  the  systematic  removal  of  the  lymph  glands  is  not  attempted. 

The  patient  is  put  on  a  light  diet  twenty-four  hours  before  the 
operation.  The  pubis  and  abdomen  are  shaved  and  prepared  on  the 
afternoon  preceding  the  operation.  The  prepared  parts  are  protected 
with  dry  sterile  dressings.  On  the  morning  of  operation  a  soapsuds 
enema  is  given,  which  is  followed  by  a  vaginal  douche  of  */2  per  cent 
lysol  solution.  Preliminary  to  the  anesthetic,  she.  is  given  *4  grain 
morphin  and  i/ioo  grain  of  atropin. 

There  is  considerable  discussion  as  to  the  best  type  of  anesthetic. 
Many  surgeons  advocate  lumbar  anesthesia,  yet  it  is  usually  found  in 
America  that  women  of  the  better  class  are  not  so  readily  made 
insensitive  by  this  method.  This  method  of  narcosis  has  the  very 
great  objection  that  it  does  nothing  to  prevent  the  patient  from  experi- 
encing the  horror  of  being  awake  during  an  operation  which  may  last 
two  and  a  half  hours  or  more.  The  advocates  of  lumbar  anesthesia 
claim  that  it  is  superior  to  inhalation  anesthesia  in  cases  presenting 
heart  or  kidney  complications.  We  are  of  the  firm  belief,  however, 
that  operation  is  not  wisely  done  on  patients  with  heart  or  kidney  com- 
plications. They  are  best  treated  by  radium. 

Disinfection  of  the  Vagina. — Opinions  differ  as  to  the  extent  and 
the  proper  time  for  preparing  the  cancerous  ulcer.  Kronig  empha- 
sizes the  modern  trend  when  he  states  that  he  fears  curetting,  because 
it  may  disseminate  the  carcinoma  cells  into  the  deeper  structures,  and 
because  those  already  present  cannot  be  destroyed  by  this  m-ethod. 
He  merely  sears  the  growth  with  the  actual  cautery  just  before  the 
abdominal  operation.  Bumm  favors  curetting  the  day  before  the 
operation.  He  attempts  to  break  down  all  cancer  structures  with  a 
sharp  curette,  and  sears  the  surfaces  with  a  Paquelin's  cautery.  Per- 
sonally, we  feel  that  a  preliminary  treatment  with  radium  ten  days 
before  the  operation  is  a  very  great  aid  to  the  treatment,  provided  it 
may  be  done  without  anesthesia,  since  cancer  cases  do  not  usually 
do  well  after  two  anesthesias  in  close  sequence.  We  feel  that  no  matter 
what  is  done,  the  cancerous  ulcer  cannot  be  freed  of  the  myriads  of  pus 
organisms.  We  advise  cauterizing  lightly  as  the  first  step  of  vaginal 
preparation  just  preceding  operation.  The  vagina  is  then  cleansed 
with  green  soap  and  water,  irrigated  with  a  solution  of  l/4  per  cent 
lysol,  which  is  followed  by  an  irrigation  of  70  per  cent  alcohol.  A 


228  PELVIC   NEOPLASMS 

vaginal  pack  is  now  inserted  firmly  against  the  carcinomatous  ulcer. 
Previous  to  the  insertion  of  the  pack,  the  bladder  is  catheterized. 
Neither  the  instruments  used  nor  the  room  in  which  the  preparation 
is  done  should  be  used  for  the  operation.  The  patient  is  then  placed 
flat,  and  the  abdomen  is  prepared  for  operation  by  cleansing  with 
alcohol,  ether,  and  ^  tincture  iodin  solution. 

Abdominal  Incision. — There  has  been  considerable  discussion  as  to 
the  type  of  incision  which  will  secure  the  best  exposure.  It  has  been 
our  experience  that  the  ordinary  midline  incision  from  the  symphysis 
to  the  umbilicus  is  most  satisfactory.  Some,  as  Bumm,  cut  trans- 
versely some  of  the  lower  mesial  fibers  of  the  recti  muscles;  others,  as 
Mackenrodt,  make  a  horse-shoe  incision  through  the  skin  and  all  the 
other  abdominal  layers.  The  incision  runs  a  couple  of  finger  breadths 
above  the  anterior  pelvic  brim.  Following  the  opening  of  the  peri- 
toneum, the  skin,  fat,  and  peritoneal  edges  should  be  protected  from 
carcinomatous  cells  or  infected  material  by  properly  draping  the  mar- 
gins of  the  incision  so  that  no  part  of  the  abdominal  wound  is  left 
exposed.  We  see  nothing  but  disadvantages  in  suturing  together  skin 
and  peritoneal  edges.  The  patient  is  placed  in  the  elevated  pelvic 
position  as  soon  as  the  anesthetic  has  taken  effect,  and  before  the 
abdomen  is  opened.  This  facilitates  the  packing  off  of  the  intestines, 
since  they  have  had  time  to  accommodate  themselves  in  the  upper 
abdomen.  Heavy  rubber  dam  pack,  about  thirty-six  inches  square,  is 
excellent  for  holding  back  the  intestines.  Self-retaining  retractors  give 
satisfactory  exposure. 

Separate  Steps  of  the  Operation. — The  upper  abdomen  is  inspected 
and  searched  for  evidence  of  metastases.  They  may  be  found  on  the 
liver,  near  the  gall-bladder,  or  in  the  omentum.  They  cannot  well  be 
located  on  the  vault  of  the  diaphragm.  The  broad  ligament  should  be 
carefully  palpated  to  determine  its  condition,  and  definitely  trace  the 
extent  of  infiltration.  The  glands  at  the  bifurcation  of  the  common 
iliac  v.essels  should  next  be  palpated.  If  they  are  of  normal  size  they 
can  scarcely  be  felt.  The  glands  on  the  anterior  surface  of  the  sacrum 
are  next  palpated.  If  the  cancer  is  present  as  a  cancerous  ulcer,  the 
glands  are  likely  to  be  enlarged,  but  this  does  not  always  mean  car- 
cinomatous invasion.  The  uterosacral  ligaments  are  now  traced  to 
their  attachments  in  the  wings  of  the  sacrum.  The  cancer  extends  out 
from  the  uterus  more  commonly  on  the  left  side.  If  it  appears  that  the 
disease  has  spread  so  far  that  the  entire  growth  cannot  be  removed,  the 
operation  should  be  abandoned.  A  simple  hysterectomy  should  not 
be  undertaken. 

The  fundus  of  the  uterus  is  elevated  by  two  heavy  clamps  placed  on 
the  upper  margins  of  the  broad  ligament  in  order  to  avoid  the  chance 
of  breaking  through  the  uterus  in  the  presence  of  a  pyometra.  The 
uterus  is  pulled  toward  the  symphysis  and  away  from  the  broad  liga- 


TREATMENT  OF  CANCER  OF  THE  CERVIX        229 

ment  which  is  to  be  first  opened.  The  ovarian  vessels  are  now  tied 
doubly  with  chromic  No.  2  sutures,  after  which  the  round -ligament  is 
tied  close  to  the  pelvic  wall.  A  crescent-shaped  incision  is  made  in 
the  broad  ligament  from  the  ovarian  vessels,  through  the  round  liga- 
ment, to  the  vesico-uterine  fold  of  peritoneum  in  the  midline.  The 
loose  connective  tissue  of  the  broad  ligament  is  now  separated  from 
the  pelvic  walls  by  blunt  dissection.  The  connective  tissue  strands  run 
in  the  general  direction  of  the  ureters  and  large  vessels,  and  they 
should  be  separated  carefully  so  the  important  structures  will  not  be 
injured.  The  ureter  usually  lies  attached  to  the  median  fold  of  the 
broad  ligament,  and  may  usually  be  exposed  readily  by  opening  up  the 
connective  tissues  with  long  hemostats.  On  account  of  the  danger  of 
necrosis,  which  Sampson  and  Fickel  have  shown  may  follow  the 
destruction  of  the  vascular  network,  the  ureters  should  not  be  isolated 
above  the  structures  which  are  to  be  removed,  and  their  capsules 
should  not  be  stripped  aw.ay.  The  uterirje  vessels  now  come  into  view, 
since  they  run  in  a  direction  transverse  to  the  broad  ligament  con- 
nective tissue.  The  uterus  is  now  pulled  high  into  the  abdomen,  and 
the  detachment  of  the  bladder  from  the  cervix  is  completed  as  far 
down  as  the  insertion  of  the  ureter.  By  passing  a  clamp  along  the 
sheath  of  the  ureter,  the  uterine  vessels  are  isolated,  and  the  branch- 
ings of  the  superior  vesical  artery  may  also  be  brought  into  view.  It  is 
best  not  to  attempt  to  tie  off  the  uterine  vessels  until  the  ureter  is 
exposed  nearly  down  as  far  as  the  bladder.  Wertheim  advocates  push- 
ing an  index  finger  of  one  hand  down  along  the  ureter  and  toward  the 
bladder  to  isolate  the  uterine  vessels.  This,  to  us,  seems  unnecessary 
trauma.  Inflammatory  changes  in  the  broad  ligament  often  com- 
plicate the  dissection,  and  there  is  a  likelihood  that  there  are  dense 
adhesions  to  the  ureter.  The  same  condition  is  often  met  with  after 
preliminary  radium  treatment.  Much  fat  in  the  depths  of  the  broad 
ligament  is  another  unfavorable  condition,  and  great  care  is  necessary 
to  keep  from  getting  into  the  wrong  strata. 

Ligation  of  the  Uterine  Artery. — If  the  blood  vessels  and  ureter 
have  been  exposed  according  to  the  method  described,  there  is  usually 
little  difficulty  in  ligating  the  uterine  vessels.  These  vessels  cross  the 
ureters  transversely.  In  tying  off  the  uterine  artery  we  must  avoid 
ligating  the  superior  vesical  artery.  The  uterine  artery  and  the 
superior  vesical  artery  originate,  as  a  rule,  in  a  short  common  trunk 
from  the  hypogastric  artery.  For  this  reason,  one  should  not  tie 
too  closely  to  the  hypogastric  artery,  but  select  a  place  rather  mesial 
to  the  branching  of  the  superior  vesical  artery.  Should  the  vesical 
artery  be  tied,  gangrene  of  the  bladder  may  follow.  If  the  blood  vessels 
be  tied  too  close  to  the  hypogastric  artery,  secondary  hemorrhage  may 
occur.  Bumm  has  reported  such  a  complication  which  resulted  fatally. 
The  uterine  vessels  are  tied  with  No.  2  chromic  catgut,  and  it  is  impor- 


230 


PELVIC  NEOPLASMS 


tant  to  be  absolutely  certain  that  the  ureter  is  not  included  in  this 
ligature.  At  this  step  it  is  necessary  to  determine  whether  or  not 
•there  is  another  deep  uterine  vein  lying  immediately  beneath  the 
ureter.  If  this  is  present,  there  may  be  abundant  hemorrhage  from  it, 
since  it  is  easily  injured,  and  in  attempting  to  clamp  it,  other  hemor- 
rhages may  arise  by  further  injury  to  the  adjoining  venous  plexuses. 
Exposure  of  the  Ureter  to  the  Bladder. — The  uterine  vessels  have 
been  tied  as  close  as  one  dares  to  the  large  vessels  of  the  pelvis.  The 
ureter  is  now  elevated  from  its  parametric  attachments  and  traced  to  its 


FIG.  62. — EXPOSURE  AND  LIGATION  OF  THE  UTERINE  ARTERY  (Sampson).  The  exposure 
of  Bumm  and  Mackenrodt  is  identical  with  this  procedure  (Kelly,  Operative  Gyne- 
cology). 

insertion  in  the  bladder.  This  may  cause  much  difficulty  from 
a  technical  point  of  view,  since  the  facility  of  the  isolation  depends 
upon  the  extent  of  carcinomatous  infiltration.  If  one  elevates  the 
uterine  end  of  the  severed  uterine  artery  and  draws  it  toward  the 
uterus  over  the  ureter,  it  can  be  demonstrated  that  the  ureter  is 
attached  to  the  cervix  by  thin  bands  of  connective  tissue.  These  bands 
may  be  cut  without  difficulty  or  risk  when  they  are  put  on  slight 
tension  and  defined  by  raising  the  uterine  artery.  The  connection 
between  the  vessels  and  the  ureter  being  severed,  the  latter  can  be 
worked  out  of  its  parametric  bed.  The  vessels  with  the  lymphatics 
and  glands  remain  in  contact  with  the  uterus.  There  is  a  small  gland 


TREATMENT  OF  CANCER  OF  THE  CERVIX         231 

which  is  invariably  palpable  in  the  region  just  described.  It  is  gen- 
erally possible  to  isolate  the  ureter  by  blunt  dissection  with  a  pair  of 
forceps,  yet  in  the  event  of  inflammatory  reaction  and  the  presence  of 
infiltrated  tissue,  the  adhesions  between  the  ureter  and  the  paracervical 
tissue  may  be  very  dense.  Blunt  dissection  should  be  employed  wher- 
ever possible,  since  sharp  dissection  is  likely  to  cause  damage  by 
occasioning  hemorrhage.  The  ureter  now  bends  sharply  upward 
towards  its  insertion  in  the  bladder.  Particular  care  must  be  exercised 
in  separating  it  at  this  point,  since  here  there  are  frequently  dilated 
veins  of  the  vesicovaginal  plexus.  The  bladder  is  now  completely 
separated  from  the  cervix  so  that  the  ureteral  insertion  can  be  plainly 
seen.  There  are  a  number  of  bands  of  connective  tissue  which  run 


FIG.  63. — EXPOSURE  AND  FREEING  OF  THE  URETER  (Sampson).     The  capsule  should  not  be 
stripped  from  the  ureter  or  necrosis  may  supervene  (Kelly,  Operative  Gynecology). 

from  the  cervix  to  the  bladder,  above  and  below  the  ureter.     These 
may  be  severed  under  sight. 

Venous  Hemostasis. — By  following  the  above  directions,  one  may 
avoid  the  veins  in  the  depths  of  the  pelvis  leading  to  the  median  iliac 
vein.  The  various  steps  should  be  clearly  defined.  After  isolating  the 
ureter,  the  uterine  artery  is  ligated.  The  bladder  is  separated  in  the 
middle  and  pushed  off  on  one  side,  and  the  ureter  is  followed  through 
its  entire  course  in  the  parametrium  and  through  from  its  bladder 
attachment.  The  other  side  of  the  pelvis  should  be  treated  in  a  similar 
manner.  The  removal  of  the  roots  of  the  parametria  and  the  deep 
venous  plexuses  are  the  last  steps  to  be  completed  after  the  arterial 
blood  has  been  shut  off  from  the  vagina.  If  the  bleeding  becomes 
troublesome  in  the  depths  of  the  pelvis  and  seems  to  be  venous  in  type, 
it  is  best  not  to  attempt  its  control  by  clamps  or  sponging  to  obtain 
exposure.  This  usually  only  increases  the  hemorrhage  by  injuring 
additional  veins.  A  small  hot  abdominal  pad  may  be  compressed  on 
the  bleeding  surfaces,  and  the  operation  continued  on  the  other  side 


232 


PELVIC   NEOPLASMS 


until  all  the  arteries  leading  to  the  uterus  are  ligated.  When  the 
extirpation  has  been  completed,  it  will  be  found  generally  that  the 
bleeding  has  ceased  or  may  be  controlled  by  a  few  clamps  with  com- 
parative safety  when  the  uterus  has  been  removed  and  all  essential 
landmarks  are  in  plain  view. 

Incision  of  the  Posterior  Peritoneum  and  Separation  of  the  Rectum. 
-This  should  not  be  attempted  until  both  ureters  have  been  isolated 
through  their  entire  extent,  and  the  bladder  has  been  separated  from 
the  cervix.  The  peritoneum  posterior  to  the  uterus  is  cut  from  one 
ovarian  pedicle  to  the  other.  The  uterus  should  be  drawn  to  the 
symphysis  before  this  is  attempted,  since  it  elevates  the  pouch  of 
Douglas.  Usually  the  peritoneum  can  be  pushed  off  by  blunt  dis- 


FIG.  64. — REMOVAL  OF  THE  PARAMETRIUM  FROM   UNDER   THE  URETER  (Sampson;    Kelly, 

Operative  Gynecology). 

section.  In  our  practice  we  seize  and  elevate  the  rectum,  and  separate 
the  peritoneum  and  connective  tissue  from  the  rectum  with  dissecting 
scissors.  We  believe  that  this  is  the  most  important  step  in  the  opera- 
tion, since  it  should  be  our  aim  to  remove  all  traces  of  the  pouch  of 
Douglas.  The  rectum  is  now  separated  from  the  vagina,  which  can 
usually  be  done  by  blunt  dissection.  The  uterosacral  ligaments  are 
now  exposed  on  their  mesial  sides.  The  rectum  is  freed  as  far  back  as 
seems  safely  possible,  since  it  should  be  our  aim  to  remove  the  para- 
metrium  from  the  very  pelvic  wall. 

Extirpation  of  the  Parametrium. — It  is  a  good  rule  to  attack  the 
better  side  first,  since  the  mobility  of  the  other  is  increased  and  the 
excision  is  usually  made  easier  after  one  side  has  been  extirpated. 
Wertheim  has  advised  right  angle  clamps  to  close  off  the  car- 
cinomatous  crater  in  the  vagina  during  this  step  of  the  operation.  They 
are  widely  used,  but  to  us  have  many  objections,  chief  of  which  is  that 


TREATMENT  OF  CANCER  OF  THE  CERVIX 


233 


they  obscure  the  field  in  the  depth  of  the  pelvis.  If  a  heavy  curved  broad 
ligament  clamp  be  placed  on  the  sides  of  the  paracervical  tissue  and 
traction  exerted,  the  roots  of  the  parametrium  will  be  seen  to  run  out 
in  broad  masses  when  they  may  be  excised  from  the  pelvic  wall  by 
blunt  or  sharp  dissection.  The  excision  begins  at  the  anterior  para- 
metric roots  which  are  exposed  by  holding  the  bladder  upward  and 
outward,  while  the  operator  makes  strong  traction  on  the  vaginal 
clamp.  When  the  anterior  part  of  the  parametrium  is  severed,  which 
may  be  done  with  comparatively  little  bleeding,  one  may  work  along 
the  sides  laterally  and  out  from  the  rectum,  and  peel  the  connective  and 
fatty  tissues  as  far  as  the  posterior  root  of  the  parametrium.  It  is  well 


FIG.  65. — RAW  SURFACES  AFTER  REMOVING  UTERUS  AND  PARAMETRIUM. 

at  this  stage  to  place  heavy  broad  ligament  clamps  on  the  uterosacral 
ligaments  close  to  the  plevic  bone.  They  contain  vessels  which  may 
cause  troublesome  bleeding.  Incision  is  made  under  direct  sight  with 
the  ureter  in  full  view.  Care  should  be  taken  that  the  rectum  is  freed 
far  enough  down  so  that  the  upper  half  of  the  vagina  is  in  full  view. 
The  vagina  may  now  be  incised  under  direct  sight,  cutting  from  the 
side  while  an  assistant  seizes  the  vaginal  stump  with  mouse-tooth 
hemostats,  so  there  may  be  no  overflow  of  purulent  fluids  into  the  raw 
bed  created  by  the  operation.  As  soon  as  practical,  all  raw  surfaces 
should  be  walled  off  with  gauze  to  prevent  contamination.  Often  the 
cul-de-sac  is  obliterated  by  adhesions;  there  may  be  difficulties  in  suf- 
ficiently freeing  the  rectum.  This,  however,  is  the  most  important  step 
of  the  operation,  and  the  operation  will  fail  if  at  least  the  upper  third 


234  PELVIC   NEOPLASMS 

of  the  vagina  is  not  removed.  The  two  vaginal  edges  are  brought 
together  and  closed  from  the  sides  with  interrupted  sutures  of  chromic 
No.  2  gut.  After  the  vagina  is  closed,  assistants  change  their  gloves, 
and  the  instruments  which  have  been  used  during  the  operation  are 
discarded,  since  they  have  become  contaminated. 

Extirpation  of  the  Glands. — This  is  the  last  step  of  the  operation 
before  closing  the  peritoneum.  Theoretically,  it  is  more  correct  to 
begin  the  operation  from  the  brim  of  the  pelvis,  and  to  remove  all  the 
lymphatic  tracts  and  ducts  as  one  works  down  toward  the  uterus. 
This,  however,  constitutes  a  tremendous  operation  by  itself,  and  should 
not  be  attempted  by  men  first  trying  the  radical  operation.  Ries 
writes  that  he  often  takes  from  an  hour  to  an  hour  and  a  half  before  he 
is  ready  to  do  the  hysterectomy.  The  majority  of  men  extirpate  only 
the  enlarged  glands,  which  is  not  a  logical  performance,  beginning  at 
the  periphery  and  working  down  from  the  bifurcation  of  the  common 
iliac  artery.  There  are  many  bleeding  vessels  which  must  be  tied,  and 
often  there  is  difficulty  in  freeing  inflammatory  glands  from  the  large 
veins. 

Closing  the  Peritoneum. — The  method  of  closure  depends  upon 
whether  there  is  subsequent  drainage.  All  agree  that  the  anterior 
peritoneum  should  be  sewed  to  the  anterior  flap  of  the  vagina  with 
interrupted  catgut  sutures.  This  aids  in  the  hemostasis  for  the  bladder 
wall,  and  aids  in  its  support.  It  is  also  an  important  step  in  preventing 
paresis  of  the  bladder  and  the  subsequent  cystitis.  The  lateral  angle 
of  the  vagina  must  be  sutured  with  care,  and  attention  paid  particularly 
to  hemostasis  and  avoiding  the  ureters.  The  rectum  is  now  supported 
by  attaching  the  posterior  peritoneum  to  the  posterior  vaginal  wall. 
The  raw  surfaces  in  the  pelvis  have  been  greatly  reduced  in  size  by  this 
procedure.  The  floor  of  the  parametric  stumps  should  be  dry  and 
without  oozing.  Absolute  hemostasis  is  necessary  if  one  desires  to 
close  without  drainage.  In  such  event  the  peritoneal  margins  are 
united  with  a  continuous  suture  from  one  infundibulopelvic  ligament 
to  the  other.  If  the  peritoneum  is  scant  and  cannot  be  closed  without 
tension,  interrupted  sutures  should  be  used.  Or  if  closure  is  impossible 
in  this  manner,  the  sigmoid  may  be  brought  across  the  pelvis  and 
sutured  to  the  anterior  bladder  flap  so  that  the  pelvis  is  cut  off  from  the 
abdominal  cavity.  The  vagina  may  now  be  tamponed  with  gauze  as 
firmly  as  possible  to  make  pressure  upon  the  parametric  wounds  as 
far  out  as  possible. 

Drainage. — The  great  majority  of  men  use  drainage  after  this 
operation.  After  the  anterior  peritoneal  flap  is  sewed  to  the  anterior 
vaginal  wall,  an  assistant  removes  the  vaginal  pack  which  was  laid 
before  the  operation.  A  two-inch  vaginal  pack  is  placed  through  the  abdom- 
inal wound  into  the  stump  of  the  vagina,  and  is  cut  on  the  free  end  so  there 
may  be  two  wicks  for  draining  the  parametrium.  The  outer  third 


TREATMENT    OF    CANCER    OF    THE    CERVIX 


235 


of  the  vagina  is  closed  in  such  cases,  and,  occasionally,  the  pos- 
terior vaginal  wall  is  incised  so  that  there  may  be  an  opening  through 
which  the  serum  may  freely  drain  from  the  denuded  areas.  The  two 
gauze  wicks  are  laid  loosely  in  the  sides  over  the  parametric  denuda- 
tion, taking  care  that  they  do  not  come  in  contact  with  the  ureters.  If 
they  do,  they  may  cause  necrosis  and  subsequent  fistulae.  The  peri- 
toneum is  now  closed  over  the  drains  and  the  sigmoid  sutured  across 
to  complete  the  separation  of  the  abdominal  and  pelvic  cavities.  If 
drainage  is  used,  it  should  remain  in  situ  for  five  days,  a  short  piece  being 
removed  daily  after  forty-eight  hours.  If  the  tampon  is  removed  too 


FIG.  66. — DRAINAGE  AFTER  REMOVAL  OF  UTERUS  AND  PARAMETRIUM.  Gauze  drain  has' 
been  inserted  into  the  vagina.  The  rectum  and  bladder  have  been  attached  to  the 
posterior  and  anterior  vaginal  wall.  Right  half  of  figure  shows  peritonealization. 

early,  secondary  hemorrhage  may  result  from  infection,  and  even  a 
fatal  issue  may  follow  if  secretions  have  been  profuse  and  hemostasis 
was  not  good  at  operation. 

Closing  without  Drainage. — The  experience  of  Bumm  is  most  help- 
ful in  connection  with  closure  without  drainage.  It  is  Bumm's  belief 
that  the  most  careful  and  thorough  peritonealization  is  of  the  greatest 
importance,  and  is  responsible,  together  with  closing  without  drainage, 
for  the  reduction  of  mortality  which  has  occurred  in  his  clinic.  When 
the  free  surfaces  of  the  wounds  were  drained  with  gauze  into  the 
vagina,  there  was  30  per  cent  mortality  for  138  cases.  In  35  per  cent 
of  the  mortality,  suppuration  and  necrosis  occurred  in  the  tamponed 
cavities  from  which  there  developed  ascending  peritonitis.  Before  he 
was  willing  completely  to  abandon  drainage,  he  placed  a  small  drain  in 


236  PELVIC  NEOPLASMS 

the  lower  angle  of  the  pelvic  peritoneum  and  carried  it  out  through  the 
vagina.  During  this  period  the  mortality  was  reduced  to  21  per  cent, 
and  deaths,  for  the  most  part,  occurred  from  ascending  peritonitis.  He 
now  closes  all  surfaces  of  peritoneum  with  a  double  row  of  sutures  to 
insure  their  remaining  in  place,  and  uses  no  drainage.  The  mortality 
of  his  last  100  cases  closed  in  this  manner  was  but  6  per  cent.  Bumm 
believes  that  the  tampons  only  excite  a.  secretion  from  the  wound, 
which  forms  an  excellent  media  for  the  growth  of  pathogenic  bacteria 
which  are  always  present  in  the  cancerous  ulcers.  If  the  peritoneum  is 
carefully  closed  at  all  points,  it  can  easily  handle  a  considerable  amount 
of  virulent  organisms. 

After  Treatment. — The  after  care  and  postoperative  treatment  is 
an  important  item  in  the  ultimate  result  of  the  operation.  The  radical 
operation  is  often  attended  with  shock,  since  it  should  require  at  least 
two  hours  for  its  completion.  It  is  a  safe  rule  that  operations  which 
last  for  a  shorter  time  are  not  likely  to  be  radical.  Much  saving  in 
time  can  be  effected  only  by  omitting  important  features  of  the  opera- 
tion. Infusions  of  saline  are  often  necessary  upon  the  operating  table, 
and  the  patient  should  be  surrounded  with  hot-water  bottles  as  the 
operation  progresses.  She  should  be  placed  in  a  thoroughly  warm  bed 
and  given  infusions.  Shock  may  be  combated  by  bandaging  the  legs 
or  the  injection  of  10  to  20  minims  of  a  i  to  1000  adrenalin  chlorid 
solution.  We  use  Murphy  drip  as  a  routine,  as  soon  as  the  patient  is 
in  bed  after  the  return  from  operation.  It  is  best  given  slowly — 35  to 
40  drops  per  minute.  Cardiac  dilatation  should  be  met  by  camphorated 
oil  and  other  heart  stimulants.  Pituitrin  is  useful  in  this  connection. 
The  bladder  should  be  catheterized  at  intervals  of  five  hours.  Many 
use  a  retention  catheter  in  all  cases;  yet  this,  in  our  judgment,  has  no 
advantage.  Postoperative  bronchitis  and  hypostatic  pneumonia  may 
cause  troublesome  complications.  Their  frequency  is  reduced  by  mov- 
ing the  patient  frequently  after  operation.  The  bowels  should  be 
opened  by  a  gentle  catharsis  on  the  third  day  after  operation.  Gas 
pains  are  often  relieved  by  enemas  any  time  after  thirty-six  hours  fol- 
lowing operation.  Pituitrin  is  useful  as  an  adjunct.  When  the  patient 
is  able  to  retain  fluids,  the  Murphy  drip  should  be  discontinued.  When 
nausea  and  vomiting  are  long  maintained,  they  may  be  best  treated  by 
stopping  all  fluids  by  mouth  or  rectum  and  using  only  hypodermoclysis. 
Gastric  lavage  should  be  given  on  suspicion  of  gastric  dilatation. 

Complications. — The  chief  complications  are  from  shock  and  infec- 
tions of  the  urinary  tract.  Cystitis  is  nearly  always  a  necessary  evil, 
complicating  radical  operations  for  uterine  cancer.  Urotropin  in  10- 
grain  doses  is  advised  for  internal  medication  four  times  daily;  yet  we 
have  seen  few  results  from  this  routine  comparable  with  those  obtained 
from  irrigations  of  the  bladder  twice  daily,  with  a  half  saturated  boric 
solution,  leaving  an  ounce  of  i  to  400  silver  nitrate  solution  in  the 


237 

bladder.  Vesical  fistulae  are  likely  to  arise  spontaneously,  especially 
in  the  cases  which  have  been  complicated  by  anterior  adhesions. 
They  generally  close  without  difficulty.  More  serious  are  the  bladder 
injuries,  which  occur  near  the  ureteral  insertion,  caused  while  free- 
ing the  ureter.  They  usually  present  symptoms  a  few  days  after 
operation.  They  may  be  best  treated  by  a  retention  catheter, 
which  may  be  left  in  for  a  maximum  of  ten  days.  The  operative 
result  from  the  closure  of  these  abrasions  is  often  not  good.  The 
operation  itself  may  be  attended  with  great  difficulty.  The  ureteral 
fistulae  were  formerly  believed  to  heal  spontaneously  only  in  rare 
cases.  By  delaying  active  treatment  many  heal  spontaneously. 
Weibel  emphasizes  the  importance  of  expectant  treatment  for  this 
complication,  and  advises  the  routine  treatment  with  a  caustic.  Failing 
to  secure  closure,  the  majority  of  operators  in  this  country  attempt  to 
insert  the  ureter  into  the  bladder.  Wertheim  and  his  followers  on  the 
continent  of  Europe  usually  favor  nephrectomy,  unless  the  other  kid- 
ney has  been  found  diseased.  Before  resorting  to  this  operation,  the 
condition  of  the  bladder,  ureter  and  kidney  should  be  determined  by  a 
cystoscopic  examination.  Thrombosis  is  not  infrequent,  and  empha- 
sizes the  importance  of  handling  carefully  the  big  blood  vessels  in  the 
pelvis.  Peritonitis  is  the  frequent  cause  of  death,  and  always  threatens 
with  the  presence  of  the  infected  cancerous  ulcer. 

Complications  During  Operation. — It  is  not  always  possible  to 
determine  the  extent  of  bladder  involvement  before  operation.  The 
cystoscopic  evidence  of  malignant  invasion  of  the  bladder  has  already 
been  mentioned  (page  199).  Nor  is  it  possible  to  determine  the  con- 
dition of  the  ureters  prior  to  operation ;  yet  it  may  be  found  nearly 
impossible  to  separate  the  bladder  from  the  cervix  or  to  free  the  ureters 
from  the  parametria  because  of  fixation.  When  the  latter  occurs,  there 
is  usually  a  hydro-ureter  above  the  point  of  fixation.  Some  have 
claimed  that  if  the  ureter  cannot  be  freed  without  much  trauma,  it  is 
better  to  resect  the  terminal  part  of  the  duct  and  implant  it  in  the 
bladder.  Sampson's  experience  does  not  bear  this  out,  since  he  found 
that  secondary  infection  of  the  kidney  was  so  common  as  to  constitute 
the  rule,  when  the  ureter  was  cut  and  transplanted  by  a  careful  method. 
The  majority  of  men  proceed  with  the  operation,  since  they  have 
usually  lost  the  chance  to  withdraw  when  the  operation  has  progressed 
to  this  point.  The  technic  for  ureteral  transplantation  is  as  follows: 
the  upper  end  of  the  severed  duct  is  grasped  with  two  silk  sutures  for 
a  guy;  a  clamp  is  passed  into  the  bladder  through  the  urethral  orifice 
and  an  opening  is  made  into  the  fundus  of  the  bladder;  the  sutures, 
designed  for  use  as  guy  ropes,  are  grasped  and  the  ureter  is  pulled  into 
the  bladder  for  a  distance  of  I  or  2  centimeters.  The  ureter  is  then 
attached  with  a  few  stay  sutures  to  the  bladder  wall,  taking  care  that 
there  is  no  tension  on  sutures  in  the  wound.  An  exact  peritoneal 


238  PELVIC   NEOPLASMS 

covering  completes  the  process.  When  the  ureter  is  fairly  short,  the 
bladder  may  be  freed  and  fixed  to  the  iliac  fossa,  which  will  prevent 
tension  on  the  sutures  uniting  the  ureter  in  the  bladder  wall.  If  the 
ureter  has  been  cut  accidentally,  a  ureterostomy  is  done  by  implanting 
the  upper  end  of  the  duct  into  a  slit  in  the  vesical  end.  If  too 
much  of  the  duct  has  been  destroyed  or  cut  away  to  permit  any  of 
these  precedures,  and  it  does  not  seem  good  judgment  to  attempt  the 
removal  of  the  kidney  at  the  time,  the  upper  end  of  the  ureter  may  be 
tied  off  and  the  lower  end  of  the  duct  freed  from  its  supports,  leaving 
the  kidney  to  determine  its  own  problem.  Various  things  may  happen 
in  the  latter  event.  Spontaneous  atrophy  may  occur,  as  may  pyelo- 
nephritis, which  may  require  a  subsequent  extirpation.  The  rectum 
is  often  injured  during  the  separation.  Immediate  repair  is  usually 
followed  by  good  results.  Occasionally  rectal  fistulae  develop  follow- 
ing tampon  drainage.  They  also  usually  close  spontaneously.  Injuries 
to  the  deep  blood  vessels  in  the  pelvis  may  readily  occur  during 
attempts  to  remove  the  lymphatic  glands.  Even  the  external  iliac  vein 
may  be  traumatized.  There  are  reports,  however,  of  its  successful 
suture. 

Mackenrodt's  Operation. — The  usual  preparation  of  the  vagina  and 
abdomen  are  carried  out.  The  patient  is  put  in  the  high  pelvic  eleva- 
tion. Mackenrodt  advocates  the  employment  of  a  horseshoe-shaped 
incision  made  as  follows :  the  skin  is  put  upon  the  stretch  transversely 
and  an  incision  is  made  down  through  the  fascia  of  the  recti  muscles, 
the  incision  beginning  about  two  inches  above  the  symphysis  and  con- 
tinuing laterally  upward  and  outward  to  a  point  opposite  the  anterior 
superior  spines;  the  fascia  of  the  recti  muscles  are  now  split  along 
the  line  corresponding  to  the  skin  incision.  The  muscles  are  sepa- 
rated in  the  midline,  and  divided  transversely  some  3  or  4  centimeters 
above  their  insertion.  The  peritoneum,  together  with  the  epigastric 
vessels,  is  now  pressed  downward,  and  the  fascia  connecting  the  recti 
and  oblique  muscles  is  divided  parallel  to  the  skin  incision.  The  peri- 
toneum is  next  divided  above  the  bladder  along  the  line  of  the  skin 
incision,  out  to,  but  not  through,  the  epigastric  vessels.  During  this 
step  great  care  must  be  made  not  to  injure  the  bladder,  which  may 
be  loosened  from  its  attachments  about  the  symphysis  during  the  pre- 
vious manipulations.  If  the  upper  edge  of  the  organ  is  not  visible,  it 
can  be  palpated  between  two  fingers.  The  convex  upper  flap  with  its 
peritoneal  lining  is  now  pressed  backward  and  clamped  to  the  perito- 
neum of  the  upper  portion  of  the  posterior  pelvic  wall,  thus  shutting 
off  the  abdomen  from  the  pelvis  after  the  intestines  have  been  placed 
within  the  abdomen.  The  margins  of  the  wound  are  now  draped  with 
sterile  towels. 

The  peritoneal  area  which  is  to  be  extirpated,  is  outlined  by  a  line  pass- 
ing between  the  bladder  and  the  uterus,  laterally  over  the  round  and  in- 


TREATMENT  OF  CANCER  OF  THE  CERVIX         239 

fundibulopelvic  ligaments  along  the  posterior  layer  of  the  broad  ligament 
at  the  pelvic  wall,  and  mesially  across  the  rectum  at  the  level  at  which  the 
peritoneum  of  the  cul-de-sac  becomes  firmly  fixed  to  the  bowel.  The  uterus 
is  elevated  and  drawn  to  one  side,  while  the  vesico-uterine  fold  perito- 
neum is  incised.  The  round  ligaments  and  the  in  fundibulopelvic  ligaments 
are  tied  on  both  sides.  The  rectum  is  freed  from  the  posterior  surface  of 
the  uterus  and  cervix  with  sharp  and  blunt  dissection.  When  the  peritoneal 
incision  nears  the  rectum,  great  care  must  be  taken  not  to  injure  the 
ureter,  which  often  runs  close  to  the  bowel.  The  broad  ligaments  are 
opened  up,  and  the  connective  tissues  of  the  latter  are  separated  from  the 
pelvic  wall.  The  connection  between  the  cellular  tissue  and  the  pelvic  wall 
is  very  loose,  and  can  be  separated  without  bleeding  by  stripping  it  down 
with  gauze,  even  as  far  as  the  levator  fascia  and  the  origin  of  the  uterine 
artery.  This  step  is  facilitated  by  using  clamps  as  retractors  attached  to 
various  portions  of  the  broad  ligaments.  The  blood  vessels  of  the  lateral 
aspect  of  the  pelvic  wall  are  now  readily  seen.  The  adjacent  lymph 
glands  are  also  exposed  by  this  procedure. 

The  ureters  are  not  freed  or  isolated  until  both  broad  ligaments  have 
been  opened  up  in  this  manner.  The  uterus  and  parametrium  will  hang 
suspended  only  by  the  base  of  the  broad  ligament,  bladder,  and  vagina. 
The  uterine  arteries  are  ligated  near  their  point  of  origin.  It  is  best  to  cut 
them  between  ligatures  to  prevent  reflex  bleeding.  The  fibers  of  the  para- 
metrium are  now  separated  and  the  ureter  is  removed  from  its  sheath  in 
the  manner  previously  described.  Between  the  ureter  and  the  uterine  arteries 
is  a  lymph  gland  which  is  nearly  always  the  seat  of  carcinomatous  involve- 
ment. Before  the  ureter  can  be  completely  freed,  the  bladder  must  be 
separated  as  described  in  the  former  operation.  The  same  procedure  is 
done  on  the  opposite  side.  The  greatest  care  should  be  taken  to  avoid 
unnecessary  ligatures  on  the  bladder,  since  they  constitute  a  menace  to  the 
integrity  of  the  organ. 

Now  follow  the  most  important  steps  of  the  operation,  namely  the 
separation  of  the  roots  of  the  parametrium  and  of  the  paracolpium.  These 
two  structures  are  anatomically  continuous,  and  are  composed  of  the  same 
type  of  tissue.  Mackenrodt  emphasizes  the  importance  of  dissecting  them 
cleanly  from  the  floor  and  sides  of  the  pelvis,  since  he  claims  that  ligation 
and  division  of  these  structures  favor  recurrences.  The  lower  external 
portion  of  the  pelvic  parametrium  consists  of  connective  tissue  bands  which 
diverge  in  all  directions,  corresponding  to  the  distribution  of  the  lymph 
and  blood  vessels,  and  merge  with  the  sacral  pelvic  fascia,  the  obturator 
fascia,  the  rectum,  and  the  peritoneum  of  the  cul-de-sac. 

There  are  three  groups  of  veins  which  must  be  controlled  to  prevent 
loss  of  blood  and  avoid  the  prolongation  of  the  operation.  These  are: 

(a)  the  anterior  division  of  the  parametric  veins  which  empty  into  the 
obturator    vein    and    anastomose    with    a    vaginalvesical    venous    plexus; 

(b)  the  middle  division   which   empties   into  the  hypogastric   vein;   and 


2 40  PELVIC  NEOPLASMS 

(c)  the  posterior  division  which  drains  the  posterior  parametrium  and 
communicates  with  the  sacral,  hemorrhoidal,  and  with  the  veins  on  the 
rectum.  The  obturator  nerve  runs  between  the  hypogastric  roots  and  the 
pelvic  parametrium,  and  about  it  are  the  lymph  glands  of  the  hypo- 
gastric  group.  The  lymphatics  follow  the  course  of  the  anterior  divi- 
sion of  the  veins  to  the  internal  inguinal  lymph  nodes.  Around  the 
middle  group  are  lymph  tracts  which  empty  into  the  hypogastric 
glands.  In  the  posterior  upper  division  are  lymphatics  which  extend 
to  the  sacral  and  prevertebral  lymph  glands  of  the  lumbar  vertebrae. 
The  largest  lymphatics  accompany  the  uterine  vessels  and,  for  the 
most  part,  empty  into  the  iliac  lymph  glands.  Those  from  the  ureteral 
glands  also  follow  the  same  course;  less  often  they  empty  into  the 
glands  which  are  located  at  the  bifurcation  of  the  aorta.  The  iliac 
glands  also  receive  lymphatics  which  accompany  the  anterior  group 
of  veins  from  the  inguinal  region. 

The  vaginal  pack  is  now  removed  and  the  uterus  is  drawn  upward 
so  as  to  put  the  vagina  on  the  stretch.  The  anterior  vaginal  wall  is 
then  divided  at  the  level  at  which  the  ureters  enter  the  bladder.  Before 
the  incision  is  continued  posteriorly,  the  rectum  is  pushed  downward 
and  freed.  The  vaginal  edges  are  now  supported  with  clamps  which 
constitute  a  good  means  of  traction  while  the  uterus  is  removed.  The 
vaginal  cuff  is  now  closed.  The  rectum  can  now  be  freed  without 
difficulty,  and  the  connective  tissue  bands  of  the  paracolpium,  which 
extend  from  the  rectum  to  the  sacrum,  can  also  be  separated  from 
the  bone  by  pressure  with  gauze.  The  connective  tissue  bands  which 
extend  from  the  vagina  to  the  sides  of  the  pelvis  will  require  more 
careful  attention,  since  they  contain  veins  which  anastomose  with  the 
vesicovaginal  plexus,  and  the  obturator  veins  which,  if  injured,  may 
give  rise  to  troublesome  venous  hemorrhage.  Consequently,  they 
must  be  exposed  and  ligated  carefully,  without  injury  to  the  obturator 
artery,  after  which  the  connective  tissue  bands  are  stripped  off  with 
gauze  on  the  finger  or  on  a  clamp.  There  are  also,  in  this  middle 
root  of  paracolpium,  one  or  two  veins  which  empty  into  the  hypo- 
gastric  vein,  which  should  be  ligated  before  the  tissues  are  removed. 
When  the  sides  of  the  anterior  portion  of  the  paracolpium  are  freed, 
the  whole  mass  of  deeper  pelvic  connective  tissue  and  vagina  will  be 
held  only  by  the  fascial  insertions  on  the  anterior  sides  of  the  pelvic 
cavity.  These  may  readily  be  severed  with  scissors.  The  connective 
tissue  mass  comes  away  under  traction  in  long  bands  which  contain 
lymphatics  of  the  rectal  and  sacral  regions.  The  tissues  thus  removed, 
consisting  of  vagina,  uterus,  adnexa,  and  the  shaggy  connective  tissue 
of  the  parametrium  and  paracolpium,  form  quite  a  bulky  mass.  Hemor- 
rhage is  now  controlled  and  any  further  lymph  glands  that  are  pres- 
ent may  be  removed.  These  are  found  to  consist  of  the  obturator, 
inguinal,  and  iliac  glands.  If  the  connective  tissue  has  not  been 


TREATMENT  OF  CANCER  OF  THE  CERVIX         241 

thoroughly  removed,  many  of  the  glands  may  be  overlooked  as  they 
lie  in  masses  close  about  the  vessels.  He  now  drains  to  the  vagina 
from  the  raw  surfaces  in  the  pelvis,  and  is  most  careful  to  prevent  the 
drain  from  coming  in  contact  with  the  ureters.  The  peritoneal  layers 
are  closed  over  the  pack,  the  rectum  being  united  to  the  vesical  flap. 
The  abdominal  wound  is  closed  in  layers,  the  muscle  and  fascia  being 
united  by  wires. 

Complications. — The  fatalities  have  come  chiefly  from  albuminuria 
and  nephritis.  These  complications  have  occurred  20  times  in  70 
cases,  8  of  them  with  fatal  result.  Necrosis  of  the  bladder  occurred 
22  times,  due,  he  believed,  to  involvement  of  the  bladder  wall  either 
with  carcinoma  or  inflammatory  processes.  In  15  cases  the  bladder 
was  fixed  so  firmly  to  the  uterus  that  its  separation  resulted  in 
an  injury  to  the  wall.  Carcinoma  was  found  in  the  bladder  wall  in  10 
cases,  and  in  the  connective  tissue  between  the  bladder  and  uterus 
in  4  cases.  He  enucleated  the  ureter  in  48  cases  from  an  infiltrated 
broad  ligament.  There  was  necrosis  in  3  cases.  The  ureters  had  to 
be  excised  in  3  cases,  since  they  could  not  be  separated,  and  the  free  upper 
ends  were  then  transplanted  into  the  bladder.  Only  one  of  these  cases 
resulted  successfully,  death  following  one,  and  a  fistula  into  the  rectum  in 
the  other.  The  ureters  were  incised  accidentally  during  two  operations 
in  cases  in  which  they  lay  in  the  fold  of  Douglas  and  were  cut  through 
in  the  first  stages  of  the  operation.  Transplantation  was  performed 
in  both  cases  with  resulting  death  in  one  and  recovery  in  the  other. 
The  after  care  does  not  vary  from  the  preceding  operation. 

Burnm's  Operation. — Bumm  believes  that  the  success  of  a  radical 
removal  of  a  carcinomatous  cervix  depends  upon  exposure  of  the  so- 
called  vascular  areas  in  the  depths  of  the  pelvis.  He  ligates  the  ovarian 
vessels  on  both  sides,  opens  up  the  peritoneum  from  the  insertion  of 
the  mesosigmoid  on  the  left  and  the  mesocecum  on  the  right,  clamps 
and  cuts  the  round  ligament,  and  continues  hi=  incision  to  the  attach- 
ment of  the  bladder  and  cervix.  On  separating  the  broad  ligaments 
from  the  lateral  pelvic  walls,  the  iliac  vessels  and  the  ureters  are  easily 
brought  to  view.  In  the  upper  portion  of  the  exposed  area  is  seen  the 
common  iliac  vessels  at  the  point  of  their  division.  When  the  posterior 
layer  "of  the  broad  ligament,  to  which  the  ureter  is  fastened,  is  drawn 
toward  the  median  line  the  origin  of  the  uterine  artery  is  exposed,  as 
are  the  lymph  glands  in  these  so-called  vascular  areas.  The  ureter 
and  the  vessels  are  now  freed,  and  the  lymph  glands  in  the  vascular 
triangle  are  loosened  at  the  same  time.  All  small  vascular  branches 
must  be  ligated,  or  they  will  tear  and  bleed.  When  the  lymph  glands 
with  the  adjacent  fatty  and  connective  tissue  are  freed,  the  branchings 
of  the  common  iliac,  external  iliac,  and  hypogastric  arteries,  and  the 
accompanying  veins  lie  exposed  as  if  by  dissection.  The  ureter  is 
drawn  to  one  side  and  the  uterine  artery  is  now  doubly  ligated  and 


2 42  PELVIC   NEOPLASMS 

divided.  The  entire  vascular  cord  with  the  surrounding  structures 
of  fatty  tissue,  lymph  vessels  and  glands  are  drawn  to  the  midline. 
The  ureter,  which  has  been  exposed  only  to  the  point  just  above  where 
it  is  crossed  by  the  uterine  artery,  is  freed  by  blunt  dissection  as  far  as 
the  bladder.  This  separation  must  be  complete,  since  all  the  under- 
lying tissue  must  later  be  removed.  The  uterine  veins  must  be  ligated 
before  the  ureter  can  readily  be  freed.  There  are  two  of  these,  the 
larger  as  big  as  the  quill  of  a  goose's  feather,  runs  beneath  the  ureter, 
while  the  smaller  lies  above  it  together  with  the  artery. 

The  remaining  steps  of  the  operation  include  the  removal  of  the 
cervix,  upper  part  of  the  vagina,  paracervical  and  paravaginal  tissue. 
Bumm  agrees  with  Wertheim  that  the  removal  of  the  parametrium 
and  paracolpium  is  much  more  important  than  the  ablation  of  the 
lymph  glands.  The  excision  should  be  carried  out  as  far  as  possible, 
even  to  the  pelvic  walls  and  down  to  the  pelvic  diaphragm.  He  closes 
the  vaginal  stump  and  unites  to  it  the  serous  surfaces  of  rectum  and 
bladder.  As  has  already  been  sta-ted,  he  does  not  employ  drainage. 

The  Paravaginal  Operation. — Schuchard,  in  1893,  advocated  deep 
lateral  incisions  in  the  vagina  to  obtain  wide  exposure  of  the  vaginal 
vault,  cervix,  and  parametrium.  This  incision,  therefore,  facilitates  a 
wide  removal  of  pelvic  connective  tissue  by  the  vaginal  route.  The 
paravaginal  operation  was  developed  by  Schauta,  and  was  built  upon 
this  exposure  (Fig.  58).  For  fear  of  implantation  of  cancerous  material 
in  the  wound,  Schauta  recommended  that  it  be  made  as  late  as  possible. 
Schauta's  operation  carefully  dissects  and  exposes  the  ureters,  ligates 
the  uterine  arteries  well  out  to  the  walls,  removes  an  enormous  cuff 
o.f  parametric  tissue,  as  well  as  a  large  portion  of  the  vaginal  wall. 
He  emphasized  the  fact  that  the  radical  vaginal  operation  is  in  no  way 
akin  to  the  simple  vaginal  hysterectomy. 

The  operation  is  performed  in  the  following  manner:  after  the 
patient  has  been  shaved  and  the  parts  carefully  prepared,  she  is  placed 
on  the  end  of  the  table  in  the  lithotomy  position.  A  speculum  is  intro- 
duced and  the  condition  of  the  growth  inspected.  The  vagina  is  now 
cleansed,  the  speculum  reintroduced,  and  the  cancerous  ulcer  is  thor- 
oughly cauterized  with  soldering  irons  as  cauteries.  The  vulva  and 
vagina  are  now.  again  disinfected  and  the  cervix  is  steadied  with  a 
tenaculum.  A  circular  incision  is  made  in  the  upper  vagina  below  the 
growth  after  putting  the  vaginal  walls  on  tension  with  tenacula  and 
cutting  between.  In  the  early  cases  the  incision  should  be  made  at 
about  the  junction  of  the  middle  and  upper  thirds  of  the  vagina.  In 
the  later  growths,  it  should  be  located  so  that  half  of  the  vagina  can 
be  removed.  Many  prefer  the  cautery  instead  of  the  knife.  The 
vaginal  cuff  is  now  dissected  off  as  deeply  as  possible  and  sutured 
over  the  cancerous  cervix,  so  that  infectious  material  may  not  escape 
from  the  uterus  during  the  operation  and  contaminate  the  field.  Tena- 


TREATMENT  OF  CANCER  OF  THE  CERVIX         243 

cula  or  guy  sutures  are  placed  through  the  cuff  for  use  as  tractors, 
and  to  afford  landmarks  of  the  cervical  position.  There  is  some 
hemorrhage  which  results  during  this  step  which  may  be  controlled 
with  fine  ties.  A  wide  dissection  is  indicated,  because  of  the  frequency 
of  cancerous  extensions  in  the  vagina  not  visible  to  the  naked  eye. 
Schauta  insisted  that  the  bladder  be  separated  from  its  attachments 
before  the  paravaginal  incision  is  made,  since  the  latter  step  is  useless 
if  it  is  found  necessary  later  to  abandon  the  operation.  The  bladder 
is  dissected  first  into  the  midline  and  later  in  the  sides  which  can  be 
best  accomplished  by  dissection  with  the  blunt  scissors.  The  ureters 
lie  under  the  lateral  supports  of  the  bladder,  and  are  not  exposed  until 
the  next  step  of  the  operation,  when  the  parametrium  is  freed.  If  it 
is  necessary  on  account  of  the  extent  of  the  growth  to  resect  either  the 
ureter  or  the  bladder,  the  operation  should  be  abandoned  at  this  point 
before  the  peritoneal  membrane  has  been  incised.  The  paravaginal 
incision  is  now  made.  It  is,  in  effect,  only  a  wide  episiotomy.  The 
incision  on  one  side  usually  suffices,  and  is  best  made  on  the  side  of 
the  greatest  parametric  induration.  Some,  as  Staude,  recommend  that 
it  be  made  on  both  sides  as  a  routine  procedure.  Other  things  being 
equal,  the  left-sided  incision  proves  more  convenient  for  a  right-handed 
operator.  The  posterior  portion  of  the  left  labia  is  seized  with  the 
forefinger  and  thumb  of  the  left  hand  while  an  assistant  puts  the 
upper  part  of  the  labia  upon  the  stretch.  The  incision  is  made  from 
the  posterior  margin  of  the  circular  incision  in  the  vagina,  downward 
and  laterally,  through  the  posterior  portion  of  the  labia  minus  to  the 
middle  of  the  coccygeal  region.  The  whole  vaginal  tube  is  incised  in 
this  manner.  Schuchardt  states  that  the  cut  passes  through  the  left 
labium  minus,  the  paravaginal  and  pararectal  tissues,  the  levator  ani 
and  coccygeal  muscles,  the  cellular  tissue  of  the  ischiorectal  fossa,  the 
skin  of  the  perineum  and  the  left  anal  region  down  as  far  as  the 
rectum.  The  incision  in  the  pararectal  tissue  is  carried  only  far  enough 
to  the  left,  so  that  the  rectum  and  sphincter  ani  may  not  be  injured. 
A  finger's  breadth  from  the  midline  is  usually  sufficient.  There  is  copi- 
ous hemorrhage  which  cannot  be  entirely  checked  by  tying  off  bleed- 
ing points.  It  may,  however,  be  perfectly  controlled  by  packing  gauze 
into  the  wound  and  resting  the  weighted  hanging  speculum  upon  the 
pack.  The  effect  of  the  incision  is  quite  remarkable.  The  vagina  now 
appears  only  as  a  shallow  excavation,  not  more  than  an  inch  in  depth, 
and  at  the  bottom  of  it  lies  the  parametria  in  full  view. 

The  next  step  is  the  separation  of  the  ureters.  It  is  not  necessary  to 
catheterize  them  so  that  they  will  be  better  landmarks.  The  dissection  is 
made  under  sight  with  the  ureter  in  full  view.  Experience  has  shown 
that  the  ureters  are  more  likely  to  become  infected  if  there  has  been 
preliminary  catheterization.  The  dissection  of  the  bladder  is  now  con- 
tinued laterally,  and  at  the  level  of  the  internal  os  and  under  the  lateral 


244  PELVIC   NEOPLASMS 

attachment  of  the  bladder,  the  ureter  is  found  winding  around  the 
uterine  artery.  Unless  the  infiltration  is  quite  marked,  the  ureter  can 
be  freed  readily  from  its  bed.  The  uterine  vessels  are  ligated  as  far 
away  from  the  uterus  as  possible.  They  should  be  tied  as  soon  as  the 
landmarks  are  established  so  as  to  check  the  bleeding.  The  pouch 
of  Douglas  is  opened  and  the  incision  is  carried  well  out  on  the 
sides  of  the  pelvis.  The  parametrium  is  separated  from  the  rectum 
by  blunt  dissection,  during  which  step  a  branch  of  the  middle  hemor- 
rhoidal  artery  is  encountered  and  must  be  tied.  Schauta  claimed  that 
if  this  vessel  is  tied,  and  if  the  uterine  artery  has  been  ligated  high  up 
as  a  preliminary  step,  only  venous  oozing  will  result  while  the  para- 
metrium is  hooked  down  over  the  finger  and  is  cut  free  with  scissors. 
The  ureter  should  be  constantly  in  view  during  this  step  so  that  it  may 
not  be  injured.  Other  operators  have  advised  ligation  of  the  para- 
metrium before  it  is  cut  away.  Yet  no  one  who  ever  saw  Schauta 
perform  this  operation  will  believe  that  this  is  necessary.  It  is  aston- 
ishing how  easily  an  infiltrated  parametrium  can  be  removed  even 
from  the  pelvic  wall.  If  the  anterior  peritoneal  cavity  has  not  been 
opened,  this  is  now  done  when  the  uterus  will  hang  suspended  only 
by  the  tops  of  the  broad  ligament.  The  bladder  and  ureters  are  ele- 
vated, the  fundus  of  the  uterus  is  seized  and  pulled  down  while 
at  the  same  time  the  cervix  is  pushed  up  into  the  wound.  The  ovaries 
are  then  brought  into  view  and  their  vessels  are  tied,  when  the  tops 
of  the  broad  ligaments  are  cut  away  between  clamps,  or  after  hemor- 
rhage has  been  arrested  by  pedicles.  Schauta  did  not  remove  the 
tubes  and  ovaries,  claiming  that  they  are  practically  never  the  seat  of 
cancerous  extension,  a  claim  which  we  do  not  believe  is  worth, making 
if  the  operation  is  designed  to  be  radical.  The  stumps  of  the  liga- 
ments are  brought  down  into  the  wound  and  the  peritoneum  covering 
the  bladder  is  united  to  that  on  the  side  of  the  rectum.  All  raw  sur- 
faces are  made  extraperitoneal.  The  vagina  may  be  drained  or  not, 
depending  on  the  judgment  of  the  operator.  Schauta,  Schuchardt, 
Gellhorn,  and  others  who  have  used  this  operation  have  employed 
drains,  yet  we  believe  the  experience  of  Bumm  with  drainage  applies 
equally  well  to  the  same  condition  and  that  drains  should  not  be  em- 
ployed if  hemostasis  has  been  effected.  The  paravaginal  incision  is 
closed  with  catgut  carefully  approximating  all  tissues.  Retention 
sutures  should  be  used  to  reinforce  the  closure. 

The  after  care  is  the  same  as  that  of  any  serious  abdominal  opera- 
tion, namely,  to  prevent  shock  and  to  provide  for  eliminations.  Post- 
operative cystitis  is  common  and  infection  of  the  paravaginal  incision 
has  been  often  noted.  There  have  been  cases  where  carcinomatous 
elements  have  been  transplanted  into  the  incision.  If  packing  has  been 
employed  as  pelvic  tampons,  its  removal  should  begin  two  or  three 


TREATMENT  OF  CANCER  OF  THE  CERVIX        245 

days  after  the  operation,  withdrawing  an  inch  or  two  of  packing  each 
day  so  that  the  entire  drain  is  out  at  the  end  of  a  week. 

The  method  is  not  free  from  accidental  injuries,  even  in  Schauta's 
hands,  since  it  is  a  serious  undertaking,  although  the  primary  mortality 
is  somewhat  below  that  met  with  after  the  abdominal  operation.  The 
convalescence  was  uninterrupted  in  150  of  Schauta's  series  of  258  cases. 
Postoperative  cystitis  occurred  67  times  and  the  bladder  and  ureters 
were  injured  each  n  times.  The  intestines  were  injured  4  times.  The 
paravaginal  incision  broke  down  completely  in  5  cases  and  there  were 
2  cases  in  which  carcinomatous  tissues  were  grafted  into  the  wound. 
Yet  this  type  of  operation  is  particularly  favorable  for  stout  women 
in  whom  abdominal  exposure  is  gained  only  with  the  utmost  difficulty. 


OTHER  OPERATIONS  FOR  CANCER  OF  THE  CERVIX 

The  Cautery  Methods. — The  cautery  is  doubtless  the  oldest  method 
of  treatment  for  carcinoma  of  the  cervix.  The  methods  have  been 
revived  from  time  to  time.  Especially  have  the  remarkable  results 
obtained  by  Byrne  redirected  the  attention  of  American  surgeons  to 
the  possibility  of  satisfactory  treatment  by  cautery  amputations.  Byrne 
began  his  work  in  1872,  and  during  the  next  dozen  years  operated  on 
367  cases  without  mortality.  His  method  for  the  most  part  consisted 
in  the  amputation  of  the  cervix  by  means  of  a  cautery  knife.  This 
was  followed  by  burning  out  the  interior  of  the  uterus  by  similar  in- 
struments. He  claimed  cures  of  19  per  cent  for  cases  under  observa- 
tion for  five  years.  His  results  were  much  questioned  by  surgeons 
throughout  the  country,  yet  practically  all  who  knew  first  hand  of  his 
work  have  remained  more  or  less  enthusiastic  about  it.  Rawlick, 
Moore,  Madden,  Dickinson,  and  others  revived  the  method  which, 
however,  did  not  obtain  wide  vogue  throughout  the  country.  All  who 
have  used  the  cautery,  instead  of  the  knife,  claim  that  the  influence 
of  heat  extends  beyond  the  actual  field  of  operation,  which  permits  a 
more  radical  operation  than  it  would  seem  at  the  time  possible.  Bumm, 
among  others,  denies  this  and  believes  that  the  effect  of  the  cautery 
does  not  extend  more  than  i  centimeter  into  the  tissue.  Certain  it  is 
that  the  burning  done  by  a  Paquelin  cautery  on  a  piece  of  raw  meat 
does  not  extend  far  from  the  margin  of  the  scar,  as  can  be  proved 
readily  by  any  one  who  will  try  the  simple  experiment. 

Following  Byrne,  Werder  became  converted  to  the  cautery  treat- 
ment of  uterine  cancers  and  has  remained  so  enthusiastic  that  he 
abandoned  the  radical  operation  proposed  and  practiced  by  him,  which 
is  identical  in  principles  with  the  method  later  advanced  by  Wertheim. 
The  operation  first  employed  was  a  more  radical  type  of  the  method 
practiced  by  Byrne.  It  was  in  effect  a  vaginal  hysterectomy,  in  which 


246  PELVIC   NEOPLASMS 

he  used  the  Schuchardt  paravaginal  incision  in  cases  which  did  not 
permit  of  good  exposure.  Subsequently  he  used  a  combined  vaginal 
and  abdominal  operation,  because  he  found  that  the  ureters  were  not 
readily  protected  from  injury  by  the  heated  clamps  in  the  vaginal 
hysterectomy. 

Werder's  Cautery  Hysterectomy. — The  vagina  was  cleaned  with 
antiseptic  preparations  after  the  patient  had  been  shaved  and 
prepared.  The  patient  was  brought  to  the  edge  of  the  table,  the 
cervix  exposed  by  a  hanging  speculum,  and  steadied  by  a  tenaculum. 
An  incision  was  then  made  about  the  vaginal  fornix,  as  far  as  possible 
from  the  affected  area,  by  means  of  a  cautery  knife  developed  by  him 
and  kept  at  dull  heat  to  prevent  burning  through  the  blood  vessels 
without  first  sealing  them  to  obtain  hemostasis.  Werder  insisted  that 
the  proper  degree  of  heat  could  be  obtained  only  when  the  cautery 
knife  was  placed  against  the  tissues  before  the  heat  had  been  turned 
on.  Traction  was  made  upon  the  cervix  and,  as  the  base  of  the  para- 
metrium  was  charred  through,  new  areas  were  exposed.  The  dissec- 
tion in  this  manner  was  carried  through  the  base  of  the  broad  liga- 
ments and  around  the  entire  lower  uterine  segment  until  the  perito- 
neum was  reached,  care  being  taken  to  keep  the  bladder  and  bowel 
from  the  neighborhood  of  the  hot  knife.  The  peritoneum  was  then 
opened  posteriorly  by  scissors  and  the  opening  widened  by  the  fingers, 
when  the  wound  was  carefully  inspected  to  see  that  all  the  surfaces 
were  black  and  well  charred.  A  vaginal  pack  was  now  laid  and  the 
patient  prepared  for  a  laparotomy. 

A  midline  incision  was  made,  and  the  field  prepared  for  operation 
by  packing  back  the  intestines  into  the  abdominal  cavity  by  wet  saline 
gauze.  The  peritoneum  of  the  bladder  was  incised  from  side  to  side, 
cutting  into  the  vagina.  The  infundibulopelvic  and  round  ligaments 
were  then  burned  through  with  a  broad  Downe's  electrothermic  clamp 
until  the  tissues  were  well  charred  and  there  was  no  bleeding.  Later, 
Werder  used  ligatures  for  these  structures,  because  cancer  practically 
never  attacked  them.  The  greatest  care  was  taken  that  the  treated 
parts  were  properly  exposed,  so  that  adjacent  structures  could  not  be 
injured  by  the  heat.  The  broad  ligament  was  then  treated  in  a  similar 
manner,  starting  on  the  least  affected  side.  Werder  worked  with  com- 
paratively small  bits  of  tissue,  thoroughly  charring  each  one  before 
dropping  the  stump.  He  cautioned  against  dropping  a  vessel  until 
it  had  been  observed  for  at  least  one  minute  after  it  had  been  burned 
through.  If  the  directions  were  followed,  hemostasis  was  as  secure 
as  that  resulting  from  ligatures.  The  opposite  parametrium  was  then 
treated  in  the  same  way  and  the  uterus  removed  by  pushing  it  down 
through  the  vagina  or  occasionally  by  removing  it  through  a  carefully 
walled-off  field.  He  took  the  greatest  care  to  avoid  injury  to  the 
ureters.  After  the  removal  of  the  uterus,  the  vaginal  stumps  were 


TREATMENT  OF  CANCER  OF  THE  CERVIX         247 

exposed  and  the  cauterized  edges  turned  downward,  .following  which 
the  raw  surfaces  were  approximated  with  catgut  sutures.  The  perito- 
neal surfaces  from  the  bladder  and  the  rectum  were  then  covered  with 
peritoneum,  and  all  other  raw  surfaces  in  the  pelvis  were  covered  to 
secure  a  smooth  peritoneal  floor.  The  abdomen  was  then  closed. 

It  will  be  seen  that  this  operation  differs  from  the  ordinary  hyster- 
ectomy which  has  been  performed  through  the  vagina  and  abdomen 
only  in  that  the  cautery  is  used  instead  of  the  knife,  and  that  there 
are  few,  if  any,  ligatures  needed  to  secure  hemostasis.  The  ureters 
were  protected  from  injury  by  pulling  the  uterus  to  one  side.  Conse- 
quently there  is  no  removal  of  the  parametria.  The  pelvic  glands  were 
not  attacked.  In  1913,  Werder  reported  his  results.  The  primary 
mortality  was  but  5.1  per  cent.  He  states  that  46  per  cent  of  his 
cases  which  had  been  under  observation  for  five  years  were  cured. 
Four  of  these,  however,  succumbed  later  to  cancer.  His  results  are 
treated  separately  under  the  general  heading  of  results  following  oper- 
ation (page  225). 

Vaginal  Hysterectomy. — Probably,  at  the  present  time,  the  great 
majority  of  cases  of  cancer  of  the  cervix  in  America  which  have  been 
operated  have  been  treated  by  vaginal  hysterectomy.  Few  believe  that 
it  is  in  any  sense  curative,  although  it  has  been  taken  up  again  by  a 
number  of  men  who  have  felt  that  the  primary  mortality  of  the  radical 
operation  was  more  than  they  could  endure.  These  practically  with- 
out exception  confess  their  inability  to  cope  with  the  cancer  situation, 
and  perform  simple  vaginal  hysterectomy  with  the  idea  that  it  is  a 
palliative  measure,  and  may  cure  an  occasional  case  where  the  disease 
remains  limited  to  the  uterus.  Personally  we  have  never  seen  a  case 
which  was  cured  by  vaginal  hysterectomy.  We  also  have  had  a  very 
unusual  opportunity  to  judge  of  the  results  of  others  who  have  treated 
cancer  of  the  cervix  in  this  manner.  During  the  last  few  years,  we 
have  seer  a  large  series  of  cases  where  recurrence  was  almost  imme- 
diate after  this  operation,  the  patients  being  sent  to  our  clinic  for 
postoperative  radium  treatment.  For  this  reason,  the  method  will  not 
be  described.  Van  Ott  alone  recommends  the  method  as  a  proper 
measure.  His  statistics  are  given  on  page  261. 

High  Cervical  Amputation. — This  operation  was  formerly  per- 
formed with  the  idea  that  it  might  be  radical.  Very  rarely,  it  was  fol- 
lowed by  a  reported  cure.  It  has  been  entirely  superseded  by  the 
radical  operation.  It  should  not  be  done  under  any  circumstances 
(Fig.  67). 


248 


PELVIC   NEOPLASMS 


PALLIATIVE  TREATMENT  OF  CANCER  OF  THE  UTERINE 

CERVIX 

The  palliative  treatment  is  entitled  to  serious  consideration,  because 
the  vast  majority  of  cases  in  America  first  present  in  an  inoperable 


FIG.  67. — RECURRENCE  OF  CANCER  TEN  WEEKS  AFTER  CERVICAL  AMPUTATION. 

condition.  There  is  no  doubt  that  much  can  be  done  by  comparatively 
simple  measures  to  alleviate  the  pain,  control  the  offensive  odor  of  the 
disease,  and  occasionally  to  retard  the  development  of  the  growth. 

Medical  literature   is   fairly   teeming  with   the   reports   of  various 
methods  which  have  been  tried,  and  practically  without  exception  have 


TREATMENT  OF  CANCER  OF  THE  CERVIX         249 

been  superseded  by  others  which  in  turn  enjoyed  temporary  vogue. 
They  come  under  various  classes.  Some  aim  to  treat  as  general 
methods  acting  through  the  body  system,  others  have  been  designed 
to  act  as  local  measures. 

General  Methods. — These  have  aimed  to  control  cancer  by  modifi- 
cations in  the  diet,  by  administration  of  drugs,  or  by  introducing  anti- 
bodies in  the  form  of  ferments,  serum,  etc.  Some  have  recommended 
a  vegetarian  diet,  others  a  two-meal  system,  while  the  purin-free  diet 
had  some  basis  from  the  experimental  standpoint. 

Various  drugs  have  been  used  in  all  types  of  medication  by  mouth, 
by  the  rectum,  under  the  skin,  and  into  the  veins.  Arsenic  has  been 
used  in  the  form  of  Fowler's  solution,  and  in  sodium  caccodylate.  Mer- 
cury and  quinin,  decoctions  of  cinnamon,  of  violet  leaves,  alder  leaves, 
infusions  of  nettle  condurango,  chelidonium-majus,  charcoal,  chole- 
strin,  jequirity,  all  have  had  their  advocates.  Oleate  of  soda,  cinna- 
mate  of  soda,  orthocoumarate  of  soda,  have  been  given  hyperdermic- 
ally  as  has  salvarsan.  Eosin-selenium  was  developed  by  Wassermann, 
yet  has  proved  unsatisfactory.  Nearly  all  the  glands  of  internal  secre- 
tion have  been  exploited  without  definite  results.  Trypsin,  cholin,  and 
other  ferments  have  enjoyed  considerable  vogue  but  have  been  found 
useless. 

Various  caustics  have  been  employed  for  local  treatment,  usually 
after  curetting.  Sometimes  they  have  been  injected  into  the  body 
of  the  tumor.  Among  this  list  we  may  mention  fuming  nitric  acid, 
bromin  in  alcohol,  nitrate  of  silver,  methyl  blue,  acetic  acid,  formalin, 
arsenic  pastes. 

In  1884,  A.  Reeves  Jackson  introduced  tampons  of  zinc  chlorid 
after  preliminary  curettage.  Czerny  revived  the  treatment.  After 
rather  extensive  curettage,  a  tampon  of  gauze  saturated  with  30  to 
50  per  cent  solution  of  zinc  chlorid  is  packed  into  the  ulcer.  It  is 
allowed  to  remain  in  place  for  three  days,  after  which  it  is  withdrawn 
and  douches  are  given.  Some,  as  Buttersack,  have  questioned  the 
efficacy  of  the  treatment,  claiming  that  any  chemical  used  as  a  caustic 
is  quite  beyond  the  control  of  the  physician.  Yet  the  method  is  popu- 
lar, and  many  believe  it  has  a  selective  action  upon  the  cancer  cells, 
and  does  much  to  clean  up  the  ulcer. 

Acetone  Treatment. — Gellhorn,  in  1907,  introduced  acetone  to  clean 
up  the  ulcer.  His  method  is  as  follows :  the  patient  is  anesthetized  and 
all  sloughing  tissues  are  removed  with  a  curette.  The  crater  is  gently 
dried  with  cotton  pledgets.  The  vagina  and  vulva  are  then  thickly 
smeared  with  vaselin  so  that  the  acetone  may  not  come  in  contact 
with  skin  surfaces.  One  ounce  of  acetone  is  now  poured  through  a 
tubular  speculum  into  the  crater  of  the  cancer,  and  is  allowed  to  remain 
in  contact  for  twenty  or  thirty  minutes.  The  excess  of  acetone  is  now 
removed,  and  a  gauze  strip  saturated  with  acetone  is  packed  into  the 


250  PELVIC   NEOPLASMS 

ulcer  and  held  in  place  for  several  hours.  Subsequent  treatments  are 
required  two  or  three  times  weekly.  They  may  be  conducted  at  home 
or  in  the  physician's  office,  since  an  anesthetic  is  not  required.  The 
hips  are  elevated  and  the  speculum  is  filled  with  acetone.  Gellhorn 
states  that  the  patient  may  hold  the  speculum  in  place  so  that  the 
acetone  remains  within  the  vagina  and  does  not  run  over  the  skin 
surfaces.  If  it  does  come  in  contact  with  the  skin  or  rectum,  it  turns 
the  tissues  white,  and  produces  a  disagreeable  sensation  of  burning. 
This  may  be  checked  by  an  application  of  cold  water.  After  the  treat- 
ment of  a  half  hour,  the  vagina  is  dried,  and  a  cotton  tampon  is  intro- 
duced in  the  vagina  to  hold  the  walls  apart.  It  is  removed  in  a  few 
hours.  The  hygroscopic  qualities  of  acetone  cause  the  tissues  to 
shrink  rapidly  and  thus  causes  contraction  of  small  bleeding  vessels. 
Oozing  is  quickly  checked  by  the  treatment,  and  the  bleeding  surfaces 
are  converted  into  whitish  films.  There  is  considerable  contraction  of 
the  ulcer  after  a  few  treatments.  There  should  be  no  pain  resulting 
-from  the  method.  We  have  had  much  success  from  the  method,  which 
we  used  considerably  before  becoming  interested  in  radium.  We  used 
it  after  cauterization  and  did  not  curette  as  a  preliminary  treatment. 

Cauterization. — Cauterization  in  many  instances  has  brought  about 
marked  improvement  in  the  general  condition  of  the  patient  through 
its  effects  in  cleaning  up  the  cancerous  ulcer.  Occasionally,  with  the 
disappearance  of  the  septic  necro.tic  material  in  the  ulcer,  there  has 
been  improvement  in  the  feeling  of  the  broad  ligaments  which  have 
been  considerably  softened.  Lomer  has  stated  that  cauterization  has 
occasionally  caused  temporary  arrest  of  the  growth.  There  are  many 
instances  in  which  the  recurrence  of  the  disease  has  had  a  prolonged 
latent  period,  after  an  incomplete  removal  by  operation,  as  a  result  of 
the  cautery  method.  Freund  even  advocated  removal  of  the  uterus 
in  such  cases  which  appeared  to  have  improved  after  cauterization, 
claiming  that  even  the  hopeless  cases  were  given  temporary  relief. 
Our  experience  does  not  support  this  view,  and  we  feel  that  modern 
investigation  shows  that  it  is  bad  surgical  judgment.  The  advent  of 
radium  into  the  therapeutic  field  obviates  the  necessity  for  any  opera- 
tions which  cannot  be  radical. 

The  Percy  Method  of  Cauterization. — Percy  developed  the  method 
of  cauterization  by  using  large  irons  and  comparatively  low  heat.  He 
makes  a  great  point  of  the  fact  that  he  does  not  apply  heat  of  sufficient 
degree  to  burn  the  normal  tissues,  but  merely  to  make  the  cancerous 
mass  so  hot  that  the  cancer  cells  are  killed.  There  is  some  experi- 
mental basis  for  the  view  that  cancer  cells  are  not  as  resistant  to  heat 
as  are  normal  tissues.  He  insists  upon  avoiding  actual  chars,  since 
they  inhibit  the  further  dissemination  of  heat  through  the  cancerous 
tissues,  and  also  prevent  drainage.  He  states  that  charring  the  sur- 
faces also  permits  a  greater  absorption  of  broken-down  cancer  cells 


TREATMENT  OF  CANCER  OF  THE  CERVIX        251 

which  may  react  unfavorably  upon  the  body  system.  His  method  was 
taken  up  most  extensively  and  has  had  a  sufficient  trial  so  that  we 
may  judge  of  its  results.  Many  claimed  that  radical  operations  could 
be  performed  on  cases  which  had  been  considered  inoperable  before 
the  application  of  heat.  The  Mayos  operated  a  series  of  this  type  of 
cases,  as  did  Clark  of  New  Orleans.  The  authors  believe  that  the  favor- 
able results  following  the  Percy  treatment  were  more  apparent  than 
real,  and  the  softening  of  the  parametrium  followed  the  cleaning  up  of 
the  infected  ulcer  rather  than  from  controlling  the  cancer.  That  is  to 
say,  that  the  actual  extension  of  the  cancer  in  these  favorable  cases  was 
probably  not  as  .great  as  seemed  indicated  by  the  findings  at  the  time 
of  the  first  examination. 

In  his  early  cases,  Percy  merely  burned  the  cervical  growth  with 
a  large  electrically  heated  iron.  He  emphasized  the  fact  that  the 
curette  should  never  be  used  in  the  treatment.  Later,  he  advocated 
opening  the  abdomen  and  ligating  the  internal  iliac  arteries,  not  only 
to  cut  off  the  circulation  and  thus  starve  the  malignant  tissues,  but 
also  to  prevent  the  sloughing  and  hemorrhage  which  may  follow  exten- 
sive cauterization.  He  believed  also  that  the  treatment  could  be  better 
directed  if  the  uterus  were  held  in  a  gloved  hand  while  the  cautery 
was  applied.  Percy  developed  water-cooled  speculum  to  prevent 
burning  of  the  normal  tissues  of  the  vagina.  He  advocated  burning 
the  cancer  until  the  fundus  of  the  uterus  is  too  hot  for  the  assistant 
to  hold  in  his  hand  encased  in  a  medium  weight  of  a  rubber  glove.  The 
treatment  requires  at  least  two  hours  under  anesthesia.  He  states 
that  about  50  per  cent  of  the  cases  may  need  a  reapplication  of  heat. 
He  claims  that  secondary  radical  operations  should  not  be  performed, 
even  if  the  case  later  seems  to  be  operable,  since  nature  has  developed 
an  immunity  which  may  be  broken  down  by  the  operative  interference. 
He  believed  that  his  technic  was  applicable  to  95  per  cent  of  women 
with  good  kidneys  and  a  fair  heart,  suffering  from  inoperable  carci- 
noma with  the  expectation  of  arresting  the  discharge,  checking  the 
hemorrhage,  inhibiting  the  septic  absorption  and  improving  the  gen- 
eral nutrition  of  the  patient.  In  a  smaller  group  of  cases,  comprising 
about  35  per  cent  of  inoperable  uterine  carcinoma,  he  states  that  you 
may  expect  occasional  cures  if  there  are  no  metastases  outside  the 
pelvis.  He  reports  65  cases  in  this  group,  4  of  which  have  survived 
more  than  five  years.  Of  these,  one  lived  nine,  one  six  and  a  half,  and 
two  five  years.  While  Percy  mentions  other  cases  in  this  group  which 
he  states  are  clinically  free  from  cancer  from  two  to  five  years,  we  must 
disregard  them  from  the  standpoint  of  cure,  although  they  are  of  the 
greatest  interest,  since  they  first  presented  as  inoperable  cases. 

The  method  is  not  attended  with  uniformly  good  results.  Fistula 
may  develop  in  the  bladder  or  rectum.  Several  cases  have  been  re- 
ported where  death  followed  from  the  burn.  The  method  is  not  ideal 


252  PELVIC  NEOPLASMS 

theoretically,  since  laparotomy  is  necessary  as  well  as  an  operation 
which  may  last  from  two  to  two  and  a  half  hours  merely  for  palliative 
purposes.  Before  the  advent  of  radium,  the  method  accomplished 
much,  but  in  our  judgment  it  has  now  been  superseded  entirely  by 
radium. 

The  report  of  Bailey  in  1922,  suggests  that  the  Percy  method 
should  not  be  combined  with  radium  treatment.  Bailey  and  Quimby, 
writing  in  1922,  say: 

"During  the  year  1915—1916  a  Percy  or  modified  Percy  operation 
was  performed  in  thirty  cases.  The  abdomen  was  opened  and  in  all 
instances,  the  burning  was  conducted  with  an  assistant's  hand  holding 
the  uterus.  In  a  considerable  number  of  cases,  the  vessels  were  tied 
off  in  addition.  The  operation  was  followed  by  radium,  the  first  appli- 
cation usually  about  two  weeks  after  the  operation.  The  results  from 
this  procedure  were  not  good,  the  majority  of  the  cases  developing 
rectovaginal  fistulae.  However,  there  are  three  cases  that  have  re- 
mained well  up  to  the  present  (May,  1921).  In  one  or  two  patients 
the  results  following  the  ligature  of  the  vessels  were  disastrous,  leading 
to  a  sloughing  of  the  tissues  of  the  pelvis. 

"The  criticism  of  this  work  would  lead  to  the  conclusion  that  the 
blood  supply  should  not  be  interfered  with  to  the  extent  of  tying  off 
the  vessels  and  further  that  with  the  abdomen  open  and  the  uterus 
held  in  the  hands  of  an  assistant,  there  is  a  tendency  on  the  part  of  the 
operator  to  burn  too  extensively  and  beyond  what  is  advisable,  if 
radium  is  to  be  used  later.  In  other  words,  the  tissue  slougfied  away 
following  the  burning  leaves  a  very  thin  wall  between  the  cervix  and 
adjoining  parts  and  the  slough  which  regularly  follows  radium  dosage, 
applicable  to  the  treatment  of  cancer,  breaks  through  this  thin  barrier." 


METHOD  OF  CALCULATING  RESULTS 

There  has  been  the  greatest  difficulty  in  the  past  in  determining 
the  actual  results  of  operative  treatment.  Little  was  gained  by  com- 
paring the  results  of  different  surgeons,  since  there  was  usually  no 
agreement  as  to  terms  and  consequently  no  basis  for  comparison. 
Some  men  operated  only  the  most  favorable  type  of  cases,  and  claimed 
high  percentage  of  cures.  Others  also  attempted  more  advanced 
growths  and  presented  statistics  which  suffered  by  comparison,  even 
though  they  may  have  cured  a  larger  percentage  of  the  total  number 
of  cases  applying  for  treatment.  The  majority  of  these  series  grouped 
together  all  cancers  of  the  uterus,  making  no  attempt  properly  to 
classify  them.  Naturally,  therefore,  the  results  would  differ,  depend- 
ing on  the  selection  of  cases  for  operation  and  upon  the  relative  pro- 


TREATMENT  OF  CANCER  OF  THE  CERVIX         253 

portion  of  cervical  and  fundal  cancers  in  the  series,  since  adenocar- 
cinoma  of  the  uterine  body  is  much  more  easily  cured  than  are  cancers 
of  the  cervix. 

The  older  literature  has  proved  conclusively  that,  in  order  to  permit 
of  comparisons  of  the  various  types  of  operative  procedures,  there  must 
be  complete  agreement  as  to  terms.  Yet  even  with  agreement  as  to 
definitions,  and  with  cases  properly  arranged  for  study,  there  will  be 
factors  which  we  cannot  control.  There  are  variations  in  the  malig- 
nancies of  tumors  of  similar  morphology  and  histology.  The  character 
of  material  may  also  vary  in  different  years,  even  in  the  same  clinics. 
These  features,  however,  cannot  be  estimated  and  will  be  evened  up 
only  by  the  series  running  for  many  years.  Due  to  the  tremendous 
educational  movement  which  has  been  made  in  Germany,  more  early 
cases  now  apply  there  for  treatment.  No  one  who  has  seen  at  first 
hand  the  works  in  cancers  both  in  Europe  and  America  can  fail  to  be 
impressed  with  this  fact. 

At  the  present  time,  the  majority  of  students  agree  that  the  ulti- 
mate cure  of  the  disease  should  be  expressed  in  terms  of  operative 
cures  as  well  as  the  total  number  of  cases  applying  for  treatment.  Men 
were  urged  to  present  their  results  in  terms  of  absolute  cures  in  order 
to  prevent  exclusion  of  cases.  Absolute  cures  are  no  longer  of  the 
greatest  importance,  since  radium  has  come  into  the  therapeutic  field. 
Properly  presented,  operative  cures  will  completely  express  the  result 
of  the  treatment.  In  making  his  report,  the  surgeon  should  present 
a  complete  resume  of  his  entire  material,  arranged  in  such  a  manner 
as  to  show:  (i)  the  number  of  cancerous  patients  who  sought  relief 
during  the  series,  classified  as  cancer  of  the  cervix  and  cancer  of  the 
uterine  body;  (2)  the  number  who  were  operated;  (3)  the  numbei 
who  were  operable  but  who  refused  operation ;  (4)  the  number  who 
were  inoperable;  (5)  the  number  of  those  who  died  from  the  opera- 
tion; (6)  the  number  who  could  be  accurately  followed;  (7)  the  num- 
ber who  were  lost  for  purposes  of  study;  (8)  the  number  who  died 
of  intercurrent  disease  during  the  five-year  period  of  observation;  (9) 
the  number  in  whom  a  recurrence  was  observed  during  this  interval; 
and  (10)  the  number  who  were  free  from  recurrence  at  the  end  of  a 
five-year  period  of  observation. 

Werner,  Waldstein  and  Winter  have  been  especially  active  in  their 
efforts  to  develop  methods  which  will  permit  of  the  comparison  of 
cancer  series  treated  by  the  various  types  of  operations.  They  all 
agree  that  in  our  final  computation  we  should  omit  from  consideration 
cases  which  were  operable,  but  which  did  not  submit  to  the  proposed 
treatment.  There  has  been  considerable  discussion  as  to  what  con- 
stitutes operability.  Some,  in  order  to  prevent  improper  exclusion  of 
cases,  would  class  any  case  as  operable  in  which  the  operation  was 
attempted  irrespective  of  whether  it  could  be  carried  out  to  the  end. 


254  PELVIC   NEOPLASMS 

Others  believe  that  the  surgeon  should  have  the  right  to  decide  at  the 
conclusion  of  the  operation  whether  the  removal  was  or  was  not 
entitled  to  be  considered  radical.  It  probably  makes  little  difference 
so  long  as  the  cases  are  tabulated  according  as  the  operation  was  com- 
pleted, or  was  tried  but  was  abandoned  because  the  local  conditions 
prevented  the  proper  completion  of  the  operation.  The  majority  of 
German  clinics  agreed  with  Winter,  in  1908,  that  all  cases  in  which 
operation  was  attempted  should  be  considered  as  operable  unless  the 
local  conditions  prevented  the  radical  operation  from  being  carried  out 
to  the  end.  Wertheim,  however,  in  order  to  avoid  the  appearance  of 
exclusion  of  cases  counted  as  radical  all  the  operations  that  were 
attempted  and  completed,  even  with  restricted  resections. 

The  primary  deaths  may  be  excluded  in  calculating  the  operative 
cure  on  the  ground  that  cancer  kills  unless  cured  by  operation,  although 
some  do  not  feel  that  this  is  permissible.  They  must,  however,  be 
included  in  determining  the  absolute  cure,  which  is  the  proportion  the 
cases  remaining  cured  for  five  years  bear  to  the  total  number  of  cases 
who  were  willing  to  accept  treatment,  irrespective  of  their  condition, 
that  is,  both  inoperable  and  operable. 

Cases  which  were  lost  track  of  during  -the  period  of  study  are 
excluded  from  the  calculation  of  after  results  unless  they  had  developed 
recurrence  when  last  seen.  This  seems  perfectly  reasonable,  although 
it  is  apparent  that  the  value  of  a  report  may  be  greatly  impaired  by 
the  necessity  for  excluding  any  considerable  number  of  cases  on  this 
ground. 

There  has  been  much  discussion  as  to  how  we  should  consider  and 
classify  the  cases  which  died  of  intercurrent  disease  before  the  expira- 
tion of  the  five-year  period  of  observation.  Werner  held  that  they  may 
be  regarded  as  cured  if  they  live  two  or  more  years  after  the  oper- 
ation, provided  recurrences  could  not  be  demonstrated  in  the  scars  or 
lymph  glands  by  miscoscopal  serial  sections  at  a  post-mortem  exami- 
nation conducted  by  a  skillful  pathologist.  He  claimed  that  they 
should  be  classed  as  recurrences  if  they  died  before  two  years,  even 
if  cancer  could  not  be  demonstrated.  The  heads  of  the  German  Uni- 
versity clinics  agreed  with  Winter,  in  1908,  that  the  intercurrent 
deaths  should  be  excluded  from  the  series  unless  there  was  evidence 
of  recurrence. 

The  five-year  limit  is  now  generally  accepted  as  the  time  at  which 
freedom  from  recurrence  should  be  regarded  as  an  operative  cure.  It 
does  not  follow,  however,  that  cancer  may  not  cause  death  later.  Yet 
the  number  of  cases  presenting  recurrences  after  this  time  are  so  few 
that  they  more  than  offset  the  difficulty  of  following  cases  for  a  longer 
period.  It  is  of  interest  that  the  majority  of  recurrences  during  this 
interval  are  local  rather  than  regional,  and  that  recurrences  presenting 
later  than  five  years  are  very  likely  to  be  in  the  regional  lymph  glands. 


TREATMENT  OF  CANCER  OF  THE  CERVIX  '       255 

The  literature  shows  that  only  a  very  small  percentage  of  recurrence 
develop  after  five  years.  Winter,  in  1908,  states  that  in  his  series  of 
350  cases,  there  were  only  two  which  certainly,  and  two  which  pos- 
sibly, presented  recurrences  later  than  five  years  after  operation,  and 
that  the  literature  shows  that  not  more  than  10  of  1,000  recurrences 
are  first  observed  after  this  period.  Others  think  that  the  percentage 
is  greater.  Seitz  found  that  3  per  cent  of  the  recurrences  from  opera- 
tion in  von  Winckel's  clinic  occurred  in  the  fifth  year.  Wertheim,  in 
a  series  of  his  first  250  cases  which  had  been  operated  for  five  or  more 
years,  found  78. recurrences.  Of  these,  41  developed  the  first  year; 
24  in  the  second;  6  in  the  third  year;  4  in  the  fourth;  and  3  in  the 
fifth  year.  Werder  believes  that  late  recurrences  are  more  frequent 
than  are  generally  supposed.  In  his  series  of  87  cancers  operated  by 
his  cautery  method,  8  developed  recurrences  between  five  and 
nine  years  after  operation.  Weibel,  in  1914,  stated  that  13,  or 
7.7  per  cent  of  Wertheim's  169  cases  which  had  stood  for  at  least  six 
years  had  carcinoma  again  from  six  to  eight  years  after  operation. 
One  other  case  developed  a  sarcoma  of  the  foot.  Among  the  13  cases 
which  again  presented  carcinoma,  I  was  of  the  duodenum,  I  of  the 
breast,  and  I  of  the  clitoris.  The  microscopic  picture  of  these  tumors 
was  so  different  from  that  of  the  original  tumor  that  they  were  not 
thought  to  be  recurrences.  The  remaining  10  cases  (6  per  cent)  were 
undoubted  recurrences  in  the  pelvis.  Of  the  total  number  of  13  cases, 
6  developed  in  the  sixth  year;  5  in  the  seventh  year;  and  2  between 
seven  and  eight  years.  Weibel  states  that  Wertheim's  records  show 
that  there  is  about  the  same  proportion  of  recurrences  for  each  year 
after  the  third.  Ries,  also,  observed  the  recurrence  nine  years  after 
operation,  yet,  as  has  been  stated,  the  practical  difficulty  of  keeping 
cases  under  observation  for  more  than  five  years  more  than  outweighs 
the  objection  that  recurrences  may  develop  later,  since  statistics  in 
which  a  considerable  number  of  cases  are  lost  sight  of  during  post- 
operative observation  are  not  of  great  value. 


RESULTS  OF  RADICAL  OPERATION  FOR  CARCINOMA  OF 

UTERINE  CERVIX 

Although  it  is  twenty-six  years  since  Ries  emphasized  the  impor- 
tance of  the  resection  of  the  iliac  glands,  together  with  the  parametria, 
and  twenty-three  years  since  the  advent  of  Wertheim  into  the  field, 
there  are  unfortunately  no  large  series  showing  the  results  of  radical 
operation  with  the  exception  of  Wertheim's.  As  we  have  elsewhere 
indicated,  it  is  not  easy  to  present  results  in  form  which  permit  of 
comparison  with  those  of  others.  A  good  result  should  mean  more 
than  prolongation  of  life  alone.  The  observations  of  Clark,  that  the 


256  PELVIC  NEOPLASMS 

distressing  sequelae  of  operation  which  may  make  life  a  burden  should 
be  recorded  together  with  the  results  of  the  operation,  have  remained 
unnoticed. 

Weibel,  in  1913,  reports  the  results  of  Wertheim's  cases.  During 
the  years  1898  to  1912,  there  were  1,430  cases  of  cervical  cancer  in  his 
clinic.  Of  these,  71  refused  operation;  684  were  inoperable.  A  radical 
abdominal  operation  was  done  on  675  cases,  thus  equaling  a  50  per 
cent  operability.  The  operability  was  gradually  raised  during  the 
series  :  from  42  per  cent  in  the  first  250  cases,  to  52  per  cent  between  300 
and  500  cases,  to  55  per  cent  in  the  last  175  cases.  The  mortality  for 
the  first  100  cases  was  30  per  cent;  for  the  fifth  100  cases  was  15  per 
cent;  in  the  last  175  cases  it  was  9  per  cent.  The  deaths  were  due 
chiefly  to  peritonitis,  paralysis  of  the  intestines,  degeneration  of  the 
heart,  embolus  and  pyelonephritis.  It  was  seldom  due  to  other  causes. 
Weibel  emphasizes  the  fact  that  there  is  a  rise  in  mortality  which  is 
parallel  to  an  increase  in  operability,  stating  that  men  who  operate  80 
per  cent  of  their  cases  may  have  20  per  cent  to  25  per  cent  mortality. 
In  this  connection,  we  observe  that  the  mortality  following  radical 
operation  will  be  much  less  than  that  reported  in  the  literature  when 
operations  are  restricted  to  early  growths  and  when  all  others  are 
treated  with  radium.  Wertheim's  results  for  a  five-year  period  of  ob- 
servation are  truly  remarkable.  In  all,  863  cases  were  seen  for  the 
series.  Of  these,  36  refused  operation,  -447  were  inoperable,  and  380 
were  operated  by  his  radical  operation.  Eight  cases  died  of  intercur- 
rent  disease  and  only  i  case  escaped  observation.  There  were  160  cases 
which  were  free  from  recurrence  at  the  end  of  five  years'  observation. 
This  equals  43  per  cent  of  the  cases  operated,  and  53  per  cent  of  the 
cases  surviving  operation.  (Weibel  insists  that  one  cannot  consider 
cases  which  die  following  operation  in  calculating  cure.)  In  calculating 
his  absolute  cures,  he  considers  the  series  of  863  cases.  From  these 
are  deducted  the  36  that  refused  operation  and  8  that  died  from  inter- 
current  disease.  There  remain  819  cases,  of  which  160  are  free  from 
recurrence  at  the  end  of  a  five-year  period  of  observation,  thus  equal- 
ing 19.5  per  cent  of  absolute  cures. 

There  are  comparatively  few  series  which  are  entitled  to  considera- 
tion after  the  massive  statistics  of  Wertheim.  Scheib  reviewed  the 
material  from  the  clinics  of  von  Franque  and  Kleinhans  from  1903  to 
1907.  He  found  operative  cures  for  a  five-year  period  in  25  per  cent 
of  149  cases,  and  absolute  cures  for  a  five-  to  six-year  period  of  3  per 
cent  to  5  per  cent. 

Franz  and  Zinsser,  from  January,  1904,  to  January,  1910,  had  245 
cases  of  cervical  carcinoma;  82  per  cent  were  operable;  the  primary 
mortality  was  21  per  cent.  There  were  19  cases  which  survived  the 
five-year  period  which,  therefore,  constituted  his  series  for  calculation. 
Only  3  were  free  from  recurrence,  a  cure  of  18.7  per  cent.  Franz' 


TREATMENT  OF  CANCER  OF  THE  CERVIX        257 

report  showed  that  the  mortality  rises  rapidly  with  an  increase  in 
operability.  Thus,  the  mortality  was  12.6  per  cent  in  the  cases  in  which 
the  parametrium  was  not  involved,  while  it  was  24.4  per  cent  in  the 
82  cases  which  had  infiltrated  parametria.  The  infiltration  extended 
as  far  as  the  pelvic  wall  in  21  cases  and  in  these  the  mortality  was  23 
per  cent. 

Martin  obtained  an  operative  cure  according  to  the  Waldstein 
theory,  in  19  per  cent  of  195  cases. 

Schottlaender  reports  von  Rosthorn's  cases  at  Gratz,  Heidelberg, 
and  Vienna.  Only  the  85  cases  treated  at  Gratz  include  cases  which 
have  stood  for  five  years.  There  were  27  cases  which  had  been  oper- 
ated more  than  five  years,  in  which  there  was  20  per  cent  absolute  cure. 
The  other  cases  of  the  series  included  8  cases  that  were  lost  during  the 
period  of  observation,  i  which  died  of  intercurrent  disease,  18  which 
were  alive  for  two  and  a  half  years  but  which  had  not  been  followed 
long  enough  to  be  counted  as  cured,  and  a  24  per  cent  operative  mor- 
tality. 

Zweifel's  results  were  recorded  by  Aulhorn.  The  operative  cures 
according  to  Werner's  method  were  20.46  per  cent. 

Jacobson,  in  1911,  made  an  extensive  resume  of  the  results  of  opera- 
tions by  American  and  European  surgeons.  He  collected  a  total  of 
2,765  radical  abdominal  operations.  Of  these,  2,467  were  from 
European  clinics  and  298  from  American  surgeons.  He  carefully 
checked  the  reports  and  found  that  all  of  the  operations  were  radical  in 
the  sense  that  it  is  used  in  this  article.  There  were  538  deaths  in  the 
series,  giving  a  primary  mortality  of  19.45  per  cent.  The  Europeans 
obtained  a  higher  operability  and  also  a  higher  primary  mortality  than 
the  Americans,  being  65  per  cent  operability  for  the  Europeans  to  35 
per  cent  for  the  Americans.  The  mortality  was  19.94  per  cent  for  the 
Europeans  and  15.77  Per  cent  for  the  Americans.  The  mortality  varied 
considerably  among  different  men.  Thus,  Doederlein  had  30  deaths,  or 
14.3  per  cent  in  209  operations;  Jacobs  had  6  deaths,  or  6.4  per  cent  in 
95  cases;  Klein  had  7  deaths,  or  12.8  per  cent  in  52  operations;  Zweifel 
had  17  deaths,  or  10.8  per  cent  in  192  operations.  Occasionally,  fairly 
large  series  were  operated  with  very  little  mortality.  Doederlein  had 
2  deaths  (5  per  cent)  for  40  operations;  Kronig  had  2  deaths  (4.2  per 
cent)  in  47  cases ;  Wertheim  had  3  deaths  (5.6  per  cent)  in  53  cases,  and 
Veit  had  20  cases  without  a  death. 

The  percentage  of  operative  cures  at  the  end  of  the  five-year  period 
is  given  for  von  Rosthorn  as  20  per  cent;  Veit,  30  per  cent;  Reinecke, 
35  per  cent;  Wertheim,  58.6  per  cent;  and  Polosson,  60  per  cent.  The 
percentage  of  absolute  cures  was  2.65  per  cent  for  von  Rosthorn;  19.3 
per  cent  for  Wertheim ;  58.3  per  cent  for  Mackenrodt,  five  years  after 
operation.  In  marked  contrast  to  these  figures,  the  Americans  obtained 


258  PELVIC  NEOPLASMS 

operative  cures  for  the  five-year  period  of  only  8.39  per  cent,  and  abso- 
lute cures  of  i  per  cent. 

Meyer  reviews  Doederlein's  material  from  1902  to  1.905.  There  were 
211  cervical  carcinomata  with  an  operability  of  59.7  per  cent.  The 
average  primary  mortality  was  20  per  cent,  and  varied  between  36.6 
per  cent  in  1902  to  10.8  per  cent  in  1905.  He  gives  the  results  as  29 
per  cent  of  operative  cures,  and  17.1  per  cent  of  absolute  cures. 

Hofmeier  had  393  cases  of  cervical  carcinoma  between  1899  and 
1910.  The  operability  was  52  per  cent.  The  average  mortality  was 
20  per  cent,  ranging  from  27.6  per  cent  in  the  earlier  cases  to  n.6  at 
the  close  of  the  series;  31.3  per  cent  survived  the  operation  for  five 
years  or  more;  the  absolute  cures  were  14  per  cent.  Hofmeier  omitted 
in  compilations  the  cases  lost  track  of  and  those  dead  of  intercurrent 
diseases. 

From  April,  1903,  to  September,  1904,  there  were  79  cases  of 
cervical  carcinoma  at  the  Jena  clinic  under  Kronig's  direction.  There 
were  60  cases  operated,  or  79  per  cent  operability,  with  a  primary  mor- 
tality of  25  per  cent.  There  were  living  and  well  19  cases  after  a  five- 
year  period  of  observation,  giving  operative  cure  of  32  per  cent,  and 
absolute  cure  of  25  per  cent.  The  value  of  the  operation  was  shown  to 
the  author  by  the  fact  that  12  of  the  19  cases  which  survived  the  five- 
year  period  had  marked  infiltration  of  the  parametrium.  There  were 
no  carcinomatous  glands  in  any  of  the  survivors.  Franz  succeeded 
Kronig  in  Jena  and  saw  120  cervical  cancers  between  October,  1904, 
and  March,  1907.  He  was  able  to  operate  87  of  these,  or  80  per  cent 
operability.  The  operative  mortality  was  23  per  cent.  There  survived 
operation  67  patients,  of  whom  33  per  cent  were  living  and  free  from 
recurrence  at  the  end  of  five  years.  The  operative  cure,  therefore,  was 
33  per  cent,  and  the  absolute  cure  27.5  per  cent.  Franz  believes  in 
high  operability  and  is  extremely  radical,  removing  as  much  para- 
metric tissue  as  he  possibly  can.  He  claims  that  the  wisdom  of  this 
procedure  is  shown  by  his  results  since  27.5  per  cent  absolute  cure  is 
greater  than  Kronig's  25  per  cent,  or  Zweifel's  20.5  per  cent,  or  Wert- 
heim's  18.6  per  cent.  He  refuses  to  operate  only  when  the  cancer  has 
grown  through  the  bladder  wall,  and  considers  the  parametric  infiltra- 
tion, a  solid  fixation  of  the  tumor,  and  extension  of  the  growth  to  the 
vagina  and  rectum  do  not  centra-indicate  operation.  In  this  he  differs 
from  nearly  every  other  surgeon.  When  a  recurrence  takes  place,  he 
thinks  that  it  should  be  removed  at  the  earliest  possible  moment,  and 
cites  the  instance  of  a  woman  who  had  five  operations  for  recurrence 
in  the  four  years  after  the  first  vaginal  operation  in  1905,  and  yet,  at  the 
time  of  his  report,  there  was  no  sign  of  recurrence  three  years  after 
the  last  operation. 

Peto,  in  1913,  reports  a  series  of  100  cases  operated  by  Wertheim's 
method.  Sixty-three  per  cent  of  his  material  was  operable.  The  mor- 


TREATMENT  OF  CANCER  OF  THE  CERVIX         259 

tality  was  14  per  cent.  Ten  cases  survived  operation  for  five  years  and 
more  without  recurrence.  There  were  also  31  cases  living  without 
recurrence  who  had  not  yet  stood  as  cured  for  five  years,  although 
most  of  these  had  remained  cured  between  four  and  five  years.  Recur- 
rences were  noted  in  23  cases.  There  were  13  deaths  from  intercurrent 
disease  without  evidence  of  recurrence.  Twenty  cases  of  the  series 
were  lost  sight  of. 

There  are  comparatively  few  records  of  the  results  of  American 
surgeons.  Ries  treated,  between  1897  and  1910,  32  patients  with  car- 
cinoma of  the  cervix.  Eleven  were  not  operable.  Of  the  21  operated, 
8  died  from  the  operation.  Of  the  13  surviving  operation,  2  were  not 
operated  radically,  since  the  operation  could  not  be  completed. 
Arranging  his  cases  to  show  the  results  for  five  years  or  more,  he  found 
that  there  were  16  who  applied  for  treatment  from  thirteen  to  five 
years  before  his  report.  Of  these,  he  operated  13.  One  case  was 
counted  as  lost  sight  of,  although  she  returned  with  a  recurrence  in  the 
external  inguinal  glands  nine  years  after  operation  and  was  operated 
for  a  second  time  and  followed  for  one  year.  Six  died  and  6  were  alive 
at  the  time  of  his  report  in  1911,  living  respectively  twelve  years,  I 
case;  eleven  years,  I  case;  ten  years,  I  case;  nine  years,  2  cases;  and 
seven  years,  i  case.  In  1912,  at  a  meeting  of  the  American  Gynecologic 
Society,  the  symposium  on  uterine  cancer  brought  out  fairly  repre- 
sentative reports  of  the  results  of  other  operators  in  America.  Cullen, 
personally,  performed  49  Wertheims,  with  a  primary  mortality  of  n 
cases,  or  22.4  per  cent.  There  were  26  cases  operated  for  five  years  or 
more.  Seven  of  these  died  from  operation,  I  was  lost  sight  of,  and  7, 
or  26.9  per  cent  were  cured  for  five  years.  Clark,  presenting  his  figures 
from  the  University  of  Pennsylvania  Hospital,  reported  36  radical 
operations  with  3  deaths,  or  8  per  cent.  Six  cases  were  lost  track  of, 
and  6  survived  from  four  and  a  half  to  six  years  without  recurrence. 
Kelly  reports  (Neel)  136  cases  on  which  a  radical  abdominal  operation 
was  performed  in  his  clinic  with  primary  mortality  of  28  cases,  or  2Ol/2 
per  cent.  During  the  five  years  preceding  this  report,  the  percentage 
of  operability  was  54  per  cent.  There  were  70  cases  in  whom  five  years 
or  more  had  elapsed  since  operation.  Of  these,  9  were  lost  track  of 
and  61  were  traced.  One  patient  died  of  an  intercurrent  disease.  There 
were  14  which  remained  as  cured.  The  percentage  of  operative  cures 
based  upon  the  number  of  cases  in  which  the  complete  operation  was 
done,  excluding  those  lost  track  of, 'is  23.3  per  cent.  Excluding  the 
number  of  primary  deaths  (20),  I  case  dying  from  intercurrent  disease 
and  the  number  of  cases  lost  track  of  (9),  there  remain  40  cases  of 
which  14  were  cured,  or  35  per  cent. 

Sampson  reports  that  8  of  his  25  cases  were  operated  more  than 
five  years  and  thus  may  be  studied.  There  were  2  primary  deaths.  Of 
the  6  surviving  operation,  4  are  living  and  well  without  recurrence  for 


26o  PELVIC   NEOPLASMS 

more  than  five  years.  Peterson  also  reported  that  6  of  his  cases  sur- 
vived operation  five  years  before ;  of  these,  3  are  living  and. well.  Taus- 
sig  collected  a  number  of  cases  operated  by  the  Wertheim  procedure  by 
surgeons  of  the  Mississippi  Valley  and  westward.  There  were  14  cases 
which  were  operated  more  than  five  years.  There  were  no  primary 
deaths  in  the  series.  Five,  or  41.6  per  cent,  were  living  and  well  with- 
out recurrence  at  the  erid  of  the  five  years.  • 

Cobb,  in  1915,  reports  55  Wertheim  radical  operations  perfor.med 
at  the  Massachusetts  General  Hospital  between  1900  and  1914.  There 
were  12  deaths,  or  21.8  per  cent.  Fourteen  of  the  cases  were  operated 
more  than  five  years,  and  of  these  7  or  50  per  cent,  were  alive  and  free 
from  recurrence.  Very  unfortunately,  Cobb  presents  his  results  under 
the  general  heading  of  cancer  of  the  uterus,  so  we  cannot  say  whether 
the  series  was  comprised  entirely  of  cancer  of  the  cervix  or  not.  He 
also  reports  his  personal  cases  during  the  same  period  done  in  the  same 
hospital.  There  were  31  of  these.  There  were  five  deaths,  or  16.1 
per  cent.  Of  the  6  cases  which  were  operated  for  five  years,  or  more,  5, 
or  83  per  cent,  survived  the  five-year  period  without  recurrence.  This 
splendid  series  is  also  not  available  for  critical  study  because  the  type 
of  cancer  is  not  stated. 

Results  of  the  Radical  Vaginal  Operation. — Schauta  was  the  chief 
advocate  of  this  operation.  He  published,  in  1911,  the  results  of  his  ten 
years'  experience.  During  this  time,  910  cervical  carcinomata  applied 
for  treatment.  Of  these,  445  were  operated;  44  refused  operation;  and 
421  were  inoperable.  The  primary  mortality  for  the  445  cases  was  8.9 
per  cent.  The  cases  operated  during  the  last  three  years  of  the  series 
had  only  3.7  per  cent  mortality.  During  the  first  half  of  the  ten-year 
period,  forming  his  report,  447  cases  of  cervical  carcinoma  presented 
for  treatment.  Of  these,  211  were  operated  with  an  operative  cure  of 
five  years'  standing  of  39.7  per  cent  and  an  absolute  cure  of  16.6  per 
cent.  Schauta,  on  the  basis  of  these  figures,  calls  attention  to  the  fact 
that,  while  Wertheim's  absolute  cures  are  a  little  less  than  2  per  cent 
better  than  his,  this  advantage  is  more  than  offset  by  his  higher  oper- 
ability  (51  per  cent  in  contrast  to  48.6  per  cent)  and  his  lower  operative 
mortality  (8.9  per  cent  in  contrast  to  Wertheim's  18.6  per  cent). 

Thorne  also  records  his  experience  with  this  operation.  During  the 
years  1896  to  1905,  227  cervical  cancers  presented  for  treatment.  He 
had  an  operability  of  44.2  per  cent,  a  primary  mortality  of  5.2  per  cent, 
and  an  absolute  cure  of  19.35  per' cent. 

RESULTS  OF  LESS  EXTENSIVE  METHODS 

Werder,  in  1912,  reports  his  series  operated  by  his  cautery  method 
of  hysterectomy.  As  previously  stated,  the  parametria  were  not 
removed.  Thirty-nine  cases  were  operated  more  than  five  years. 


TREATMENT  OF  CANCER  OF  THE  CERVIX 


261 


Twenty-one  of  these  were  vaginal  igni-extirpation  :  18  were  combined 
vaginal  and  abdominal  operation.  Of  these,  18,  or  46  per  cent,  survived 
the  five-year  period.  Five  of  this  group,  however,  died  subsequently— 
i  after  six  years  from  intercurrent  disease,  and  4  from  recurrence.  The 
4  recurrences  are  described  as  follows :  I  after  six  and  a  half  years 
from  carcinoma  of  the  liver;  i  after  six  years  from  involvement  of  the 
retroperitoneal  glands  and  spinal  cord;  i  after  five  and  a  half  years 
from  recurrence  in  the  lumbar  glands;  and  i  after  five  years,  place  of 
recurrence  not  known.  Rearranging  his  cases  up  to  the  time  of  his 
report,  he  found  that  13  of  the  39  cases  (33/<3  per  cent)  were  alive  and 
well,  3  having  lived  eight  years  or  more  since  the  operation;  3,  seven 
years  and  more  ;  2,  over  six  years  ;  and  5,  over  five  years.  The  mortality 
for  this  series  is  not  stated.  He  notes,  however,  that  he  had  4  deaths 
in  a  series  of  78  cases. 

Vaginal  Hysterectomy. — Von  Ott,  who  is  recognized  as  a  very 
skfllful  technician,  recorded  in  1909  his  results  by  the  simple  vaginal 
method  and  contrasted  them  with  the  results  of  the  other  methods  in 
the  following  table.  It  seems  worth  while  in  passing  to  call  attention 
to  the  fact  that  the  results  accredited  to  Wertheim,  Staude,  and 
Schauta  are  not  those  of  their  final  compilations,  and  that  few,  if  any, 
have  equaled  von  Ott's  results  with  the  simple  operation. 


Advanced 
abdominal 
method 
(Wertheim) 

Advanced 
vaginal 
method 
(Stauda) 

(Schauta) 

Simple 
vaginal 
method 
(von  Ott; 

Cases  operated  upon  for  five  years  or 
more  

116 

c8 

47 

IQI 

Deaths  following  operation    

27 

9 

9 

4 

Mortality  

2T,.^% 

i  =5  •  5% 

I0-i% 

2-1% 

Cases  kept  in  view  for  five  or  more 
years  

87 

41 

34 

I  ^2 

Absolute  percentage  of  cure  according 
to  Winter                    

24.7% 

21.0% 

16.7% 

T  c     rO? 

Absolute  percentage  of  cure  according 
to  Waldstein  

19.16% 

IS-  •>% 

iS-1% 

Frequency  of  injury  to  neighboring 
organs        ....                    

8.0% 

n.6% 

9.2% 

Treatment  of  Recurrences  Following  Operation. — A  number  of 
Europeans  have  advocated  the  operative  treatment  of  recurrence 
under  certain  conditions.  Von  Rosthorn,  in  particular,  was  an  advocate 
of  this  procedure  under  favorable  conditions.  Franz  also  operates 
recurrences  and  cites  one  case  who  had  had  five  such  operations  in  the 
four  years  following  the  first  one  and  yet  at  the  time  of  his  report,  three 
years  after  the  last  operation,  there  was  no  sign  of  recurrence.  E. 
Zweifel,  in  1914,  reports  23  cases  operated  at  Jena  for  recurrences. 


262  PELVIC  NEOPLASMS 

There  were  31  such  operations  performed  on  20  women,  30  per  cent 
of  whom  survived  without  return  of  the  growth  for  an  average  of  seven 
and  a  half  years.  While  there  is  undoubted  justification  for  such  treat- 
ment, not  only  from  the  results  cited  above  but  also  from  other  refer- 
ences in  the  literature,  the  treatment  is  at  least  debatable.  The  ques- 
tion, however,  is  not  of  paramount  importance  in  this  country  at  the 
present  time,  since  the  majority  of  cases  operated  here  are  really  inop- 
erable and  the  so-called  recurrence  is  but  the  proliferation  of  tissue 
which  was  not  removed  at  the  primary  operation.  There  is  a  vast  dif- 
ference between  removing  isolated  glands,  which  subsequently  enlarge 
because  of  carcinoma,  and  an  attempt  made  to  remove  carcinomatous 
parametria  which  were  left  at  the  first  operation. 


RADIOTHERAPY 

By  this  term  is  meant  the  treatment  of  disease  by  X-rays,  and  by 
radio-active  substances,  namely,  radium,  thorium,  and  their  products. 
This  form  of  therapy  constitutes  a  most  important  and  interesting 
addition  to  the  therapeutic  armamentarium.  Since  the  discovery  of  the 
X-ray  in  1895  by  Crookes,  and  subsequently  by  Roentgen,  and  the  recog- 
nition of  radio-active  substances  in  1896  by  Henry  Becquerel,  much 
investigative  work  has  been  done  along  these  lines  which  has  resulted 
in  a  radical  change  in  our  former  conceptions  of  the  properties  of  mat- 
ter and  energy  and  the  laws  of  physics  and  chemistry.  Since  the  isola- 
tion of  radium  by  the  Curies  in  1898,  radium  and  its  allied  substances 
have  been  employed  extensively  in  different  fields,  and  have  enjoyed 
much  popularity.  The  tremendous  interest  excited  by  radio-active 
substances  has  been  reflected  in  popular  literature,  and  the  public  has 
been  led  to  believe  that  the  fight  against  cancer  has  been  won.  In 
spite  of  the  harm  that  has  resulted  from  the  popular  dissemination  of 
such  teaching  with  its  false  sense  of  security,  it  has  nevertheless 
served  to  stimulate  real  scientific  investigation.  This  has  gradually 
resulted  in  an  understanding  of  the  action  of  radium  on  cells  of  the 
human  body,  and  with  it  has  come  a  better  idea  concerning  the  dosage, 
screening,  length  of  exposure,  and  the  limitations  of  the  treatment.  In 
consequence,  the  subject  is  now  assuming  a  definite  therapeutic  basis. 

There  are  more  than  thirty  elements  which  are  radio-active.  These 
belong  chiefly  to  three  groups,  namely,  uranium,  thorium  and  actinium. 
Uranium  is  found  in  nature  as  a  black  oxide,  pitch-blende,  as  uranates 
in  combination  with  calcium,  and  in  carnotite  combined  with  vanadium. 
Its  radio-activity  is  due  to  its  association  with  radium  which  occurs 
with  it  in  varied  proportions.  Radium  is  more  widely  disseminated 
than  is  generally  known ;  practically  all  rocks,  spring  water,  and  even 
seawater  contain  it  in  infinitesimal  amounts. 


TREATMENT  OF  'CANCER  OF  THE  CERVIX         263 

Radium. — Radium  is  an  element  of  the  strontium  barium  group. 
Its  properties  are  quite  generally  known.  It  is  derived  from  uranium, 
and  was  first  isolated  commercially  from  pitch-blende  obtained  from 
mines  in  Austria.  At  the  present  time,  it  is  isolated  from  carnotite, 
which  occurs  in  considerable  amounts  in  Colorado.  It  is  used  as  a  salt 
in  therapeutics,  since  the  rays  which  are  useful  for  treatment  are 
derived  from  disintegration  products  which  are  held  by  the  salts. 

Thorium. — The  almost  prohibitive  cost  of  radium  has  stimulated 
much  popular  and  scientific  interest  in  thorium,  which  has  been  ob- 
tained commercially  as  a  byproduct  in  the  manufacture  of  incandescent 
gas  mantles.  It  is  found  as  a  thorite  in  North  and  South  Carolina, 
Brazil,  and  Ceylon.  Its  life  period  is  unknown.  Occasionally,  it  is 
found  associated  with  a  relatively  high  per  cent  of  radium.  Employed 
in  therapeutics  such  as  mesothorium,  it  contains  about  25  per  cent 
radium.  The  activity  of  mesothorium  reaches  a  maximum  in  about 
three  years  after  its  manufacture.  In  twenty  years,  it  has  lost  half  of 
its  activity,  and  finally  its  only  energy  is  due  to  the  25  per  cent  radium, 
the  latter  losing  half  its  power  in  eighteen  hundred  years. 

Radium  Rays  and  Emanations. — The  different  types  of  rays  emit- 
ted by  radio-active  substances  may  be  distinguished  by  observing 
whether  they  are  deflected  in  a  magnetic  field,  and  by  comparing  their 
relative  absorption  by  solids  and  by  gases.  It  has  been  proved  that 
there  are  three  different  types  of  rays,  which  are  termed  Alpha,  Beta 
and  Gamma  rays.  Radium  is  constantly  giving  off  rays  and  a  radio- 
active gas  termed  emanations.  The  latter  escapes  into  the  air  under 
certain  conditions  and  rapidly  disintegrates,  passing  through  a  succes- 
sion of  changes  known  as  radium  A,  B,  d  and  C2,  D,  E,  and  F. 
Radium  A,  B,  Ci  and  C2,  are  termed  the  active  deposits  of  rapid  change. 
Radium  D,  E,  and  F  are  termed  the  active  deposits  of  slow  change. 
Only  the  former  are  of  interest  from  the  standpoint  of  therapeutics. 
If  the  radium  salt  is  inclosed  in  a  sealed  tube,  the  disintegration  prod- 
ucts are  practically  all  retained. 

The  emanations  belong  to  that  class  of  inert  gases  which,  like  nitro- 
gen, do  not  seem  to  enter  into  chemical  combination  with  other  ele- 
ments. They  possess  the  properties  of  gas,  that  is,  diffusibility,  solu- 
bility, condensation  and  liquefaction.  They  can  be  transported  from 
point  to  point  by  currents  of  air  and  can  be  separated  from  air  or  from 
other  gas  with  which  they  are  mixed  by  the  action  of  extreme  cold. 
The  emanation  is  radio-active,  ionizes  air,  and  discharges  electrical 
bodies,  affects  photographic  plates,  and  passes  through  substances 
opaque  for  light.  Emanation  may  be  compressed  into  very  small  glass 
containers  and  may  be  used  as  a  therapeutic  agent,  since  it  emits  Alpha, 
Beta  and  Gamma  rays.  The  Gamma  rays  are  the  most  valuable  ones 
for  therapeutic  purposes.  They  are  also  derived  from  radium  C1;  and 


264  PELVIC  NEOPLASMS 

C2,  and  the  activity  from  a  therapeutic  standpoint  is  derived  from  the 
products  of  rapid  change. 

Whereas  radium  salt  loses  half  its  strength  in  about  two  thousand 
years  and  may  be  regarded  as  practically  constant  for  therapeutic  pur- 
poses, the  emanation  loses  half  its  strength  in  3.8  days,  that  is,  prac- 
tically one-sixth  a  day.  By  appropriate  means,  radium  emanations 
may  be  obtained  from  the  radium  salt.  Treatment  by  emanation  has 
the  great  advantage  that  the  size,  shape  and  strength  of  the  applicator 
may  be  varied  at  will.  The  use  of  emanation,  moreover,  avoids  chance 
of  losing  the  expensive  element  following  treatment.  Because  the 
emanation  is  constantly  losing  its  strength,  allowance  must  be  made 
for  this  fact  during  the  treatment.  The  radium  element,  as  used  thera- 
peutically,  is  combined  as  a  salt  either  as  chlorid,  bromid,  or  sulphate. 

Alpha  Rays. — The  Alpha  ray  is  a  particle  of  matter  or  positively 
charged  atom  of  helium  and  is  discharged  at  a  rate  between  i/io  and 
1/20  that  of  the  velocity  of  light!  The  rays  possess  but  little  power  of 
penetration  and  are  arrested  by  a  thin  piece  of  tissue  paper  or  folds  of 
gauze.  They  produce  a  marked  chemical  change,  but  are  not  of  use 
practically  for  treatment  except  for  the  most  superficial  lesions  of  the 
skin. 

Beta  Rays. — The  Beta  ray  is  an  electron  or  small  particle  charged 
with  negative  electricity.  It  is  the  same  as  a  cathode  ray.  It  moves 
with  the  velocity  of  light,  and  its  mass  is  equal  to  about  i/ioooth  part 
of  a  hydrogen  atom.  These  rays  are  not  homogeneous,  and  for  prac- 
tical purposes  are  divided  into  soft,  medium,  and  hard  rays,  the  latter 
having  the  greatest  power  of  penetration.  They  can  penetrate  nearly 
i  centimeter  of  tissue.  The  softer  rays  cannot  pass  over  more  than  2 
millimeters  of  lead  or  1.2  millimeters  of  brass,  yet  the  harder  rays  are 
of  extreme  tenacity.  It  is  doubtful  whether  i  centimeter  of  lead  will 
completely  arrest  them. 

Gamma  Rays. — Gamma  rays  are  not  particles  of  matter  but  are 
vibrations  of  ether  similar  to  ordinary  light.  They  have  an  extremely 
short  wave  length  and  a  high  power  of  penetration,  but  are  said  to  be 
less  effective  than  Alpha  or  Beta  rays  in  producing  chemical  changes  in 
the  tissues.  These  rays  are  not  polarized  and  cannot  be  deflected  from 
their  path.  They  originate  from  disturbances  of  the  electric  com- 
ponents of  atoms  and  are  real  electromagnetic  waves.  As  has  been 
already  stated,  these  are  the  most  important  rays  in  radiotherapy. 

The  Action  of  Radium. — Wickham  can  properly  be  considered  the 
pioneer  in  the  treatment  of  cancer  by  radium.  He  began  his  work  in 
Paris  in  1906,  and  in  1913  was  able  to  publish  the  result  of  the  treat- 
ment of  1,000  cases  of  cancer  by  radium.  Dominici,  a  coworker,  devel- 
oped the  principles  of  filtration.  Abbe,  in  New  York,  first  used  radium 
for  the  treatment  of  uterine  cancers.  The  first  therapeutic  results  of 
radium  did  not  appear  to  differ  from  those  obtained  by  a  caustic.  This 


TREATMENT  OF  CANCER  OF  THE  CERVIX         265 

was  due  to  the  fact  that  so  little  radium  was  used  that  there  were  not 
enough  Gamma  rays  for  therapeutic  action,  and  that  the  soft  rays, 
which  predominate,  acted  as  a  caustic.  Larger  quantities  of  radio- 
active substances  are  used  in  the  modern  methods  of  treatment  and  are 
given  for  a  considerable  length  of  time.  The  older  idea  that  radium 
was  simply  an  expensive  and  efficient  form  of  cautery  has  been  dis- 
proved as  a  result  of  histologic  study.  There  is  no  doubt  that  radium 
has  a  marked  selective  action  on  pathologic  tissues,  although  at  the 
same  time  it  exerts  a  less  marked  influence  on  normal  tissue.  The 
Alpha  and  weak  Beta  rays  produce  chemical  changes,  while  the  hard 
Beta  and  Gamma  rays  exert  selective  action  upon  the  tumor  or 
embryonic  cells. 

The  change  produced  in  tissues  is  due  to  the  activities  of  the  proto- 
plasmic enzymes  which  are  retarded  or  accelerated,  depending  on  the 
intensity  of  radiation.  The  changes  induced  in  the  enzymes  are 
thought  to  be  largely  a  chemical  reaction.  Joly  attributes  the  effect  on 
the  tissues  to  the  ionizing  properties  of  the  rays,  a  change  analogous  to 
the  alteration  which  takes  place  on  exposing  a  photographic  plate. 
Some  believe  that  the  rays  act  as  a  stimulus  to  metabolism,  since  a 
small  dose  accelerates  and  a  strong  stimulus  retards  or  prevents  all 
metabolic  activity.  Others  hold  that  the  rays  cause  a  breaking  down 
of  tissue  with  the  production  of  lecithin  which  is  toxic  to  protoplasm. 
While  we  do  not  know  the  exact  physiologic  action  on  the  rays,  it  is 
apparent  that  the  alteration  produced  by  them  is  out  of  all  proportion 
to  the  energy  liberated.  Moreover,  a  change  that  has  once  started  may 
continue  for  weeks  after  the  primary  radiation. 

Different  types  of  normal  cells  vary  considerably  in  their  sensitivity 
to  radiation.  In  order  to  standardize  the  amount  of  tissue  alteration, 
the  amount  of  radiation  which  will  cause  an  erythema  of  normal  skin 
is  taken  as  the  unit  of  comparison.  It  is  found  that  normal  tissue,  par- 
ticularly fibrous  tissue,  is  very  tolerant.  The  lymphatic  organs  are 
especially  sensitive  and  are  easily  destroyed,  as  are  the  hair  follicles, 
and  glands  of  the  skin,  and  the  reproductive  glands.  The  endothelium 
of  the  blood  vessels  may  swell  up  even  to  occlude  the  lumen  of  the 
smaller  vessels.  Muscle  is  more  sensitive  than  is  epithelium.  Epithelial 
areas  vary  in  their  response  to  raying,  the  tongue  being  more  sensitive 
than  the  vaginal  mucous  membrane.  Burnam  found  that  the  con- 
nective tissue  of  the  cervix,  bladder,  vagina,  and  even  rectum,  could 
bear  fairly  large  doses.  He  found  that  the  ovaries  were  injured  ten 
times  as  easily  as  normal  skin,  and  that  the  vaginal  wall  was  four  or 
five  times  as  tolerant  as  skin.  The  mucosa  of  the  uterus  and  the  rectum 
are  as  tolerant  as  skin,  and  the  cervix  is  twenty  times  more  resistant. 
Young  and  immature  cells,  as  tumor  cells,  are  much  more  sensitive 
than  adult,  healthy  cells,  and  the  sensitivity  of  tumor  cells  varies 
according  to  their  age,  development,  structure,  and  situation.  Adeno- 


266  PELVIC   NEOPLASMS 

carcinoma  of  the  cervix  and  the  body  of  the  uterus  is  more  easily 
injured  than  epithelioma.  The  action  of  rays  on  the  same  type  of 
tumor  is  now  always  the  same.  There  will  come  a  period  in  every 
growth  when  the  rays  will  have  only  a  slightly  different  effect  upon  the 
malignant  cells  than  they  do  upon  the  surrounding  pelvic  tissues.  It  is 
thought  that  tumor  cells  may  acquire  a  certain  amount  of  resistance  to 
radium.  It  is  a  clinical  fact  that  many  tumors  which  do  not  respond 
to  prolonged  X-ray  treatment  will  become  materially  altered  and 
shrunken  following  exposure  to  radium.  It  also  is  a  clinical  fact  that 
the  most  efficacious  rays  are  not  those  which  are  the  most  easily 
absorbed.  The  absorption  of  Gamma  rays  must  be  very  small,  yet  they 
are  the  most  efficient  rays  for  the  treatment  of  tumors. 

The  chromatin  of  the  cells  is  most  sensitive  to  the  action  of  radium 
and  soon  exhibits  conspicuous  evidences  of  degeneration.  While  there 
is  a  marked  action  upon  the  protoplasm  as  well,  it  is  obvious  that  a  cell 
whose  chromatin  is  either  destroyed  or  injured  so  seriously  that  it  is 
incapable  of  division,  is  no  longer  dangerous  from  the  cancer  point  of 
view.  Tumor  cells  are  either  killed  or  sterilized  by  the  action  of  proper 
doses  of  radium  and  lose  their  power  of  proliferation.  Shortly  they 
degenerate,  and  are  replaced  by  connective  tissues,  formed  for  the 
most  part  by  wandering  tissue  cells. 

Microscopic  Appearance  of  tissues  Subjected  to  Radium. — Micro- 
scopic examination  of  tissues  subjected  to  radium  show  that  the  first 
noticeable  change  is  e'dema  which  infiltrates  the  tissues.  The  cell 
shortly  increases  in  size  and  loses  its  characteristic  form.  The  nuclei 
also  increase  in  size  with  a  marked  diminution  in  the  distinctness  of  the 
nuclear  structure.  Vacuolization  is  now  noted  both  in  the  nucleus  and 
the  cell  protoplasm,  and  the  tissues  are  more  vascular.  Detritus  is 
present,  and  the  cells  coalesce  into  formless  masses.  The  chromatin 
also  gathers  into  masses  which  occasionally  are  so  large  that  they  sug- 
gest artifacts.  Surrounding  the  degenerated  area  is  a  zone  of  active 
leukocytosis.  The  carcinomatous  detritus  is  finally  carried  away  by 
phagocytes,  and  the  empty  spaces  are  filled  in  by  fibrous  tissue.  On 
the  periphery  of  the  treated  zone,  the  destruction  of  cells  is  not  usually 
complete.  There  may  be  found  isolated  or  grouped  cancer  cells.  The 
subsequent  growth  of  the  fibrous  tissue  becomes  an  important  factor  in 
the  reparative  changes.  If  the  radiation  has  consisted  too  largely  of 
Beta  rays,  the  normal  tissues  may  be  broken  down,  and  the  reparative 
changes  either  postponed  or  entirely  prevented.  This  frequently  leads 
to  fistula  formation.  Some  histologic  types  of  cervical  carcinoma  are 
more  susceptible  to  radiation  than  are  others.  For  example,  the  basal 
cell  type  of  epithelioma  is  very  susceptible  to  radio-activity.  The  papil- 
lary type  of  epithelial  tumor  which  is  everting  in  form  and  in  which 
glandular  metastases  are  relatively  late  is  also  specially  susceptible  to 
radium. 


TREATMENT  OF  CANCER  OF  THE  CERVIX         267 

Technic. — Dosage  is  expressed  in  terms  of  the  products  of  milli- 
grams of  radium  or  millicuries  of  emanations  and  the  number  of  riours 
it  is  applied.  The  product  is  the  so-called  milligram  or  millicurie  hours. 
Thus,  200  milligrams  or  millicuries  applied  for  fifteen  hours  gives  a 
dosage  of  3,000  milligram  or  millicurie  hours.  Also,  50  milligrams  for 
thirty  hours,  repeated  in  a  few  days,  would  give  the  same  total  of  milli- 
gram hours.  Yet  the  physiologic  action  will  not  necessarily  be  the 
same.  A  gram  of  radium  and  a  curie  of  radium  emanation  has  the  same 
Gamma  ray  activity.  Corresponding  to  the  multiples  of  the  gram  and 
the  curie,  are  the  milligrams  and  millicuries  which  are  used  for  measur- 
ing the  activity  of  the  salts  and  emanations  respectively.  In  order  that 
records  may  permit  of  comparison,  it  is  necessary  to  state:  (i)  the 
amount  of  radium  element  or  emanation  used;  (2)  the  exact  method  of 
screening;  (3)  the  distance  between  the  container  and  the  tumor;  (4) 
the  hours  of  each  treatment;  (5)  the  intervals  between  treatments; 
and  (6)  the  total  number  of  hours  in  each  series. 

In  order  to  obtain  the  proper  therapeutic  effect  from  radium,  the 
pathologic  tissues  must  be  radiated  with  a  dose  sufficient  to  kill  them 
but  not  sufficient  to  destroy  the  normal  adjacent  tissues.  The  various 
rays  are  absorbed  by  the  tissues  in  a  constant,  uniform  manner,  even 
if  the  hard  Beta  and  the  Gamma  rays  differ  in  their  power  of  penetra- 
tion. That  is  to  say,  in  a  given  thickness  of  tissues,  there  is  a  uniform 
percentage  of  absorption  of  the  rays  which  have  passed  through.  It  is 
generally  stated  that  8  per  cent  of  the  Beta  rays  are  absorbed  by  each 
tenth  of  i  millimeter  thickness  of  tissue,  and  5  per  cent  of  the  Gamma 
rays  by  each  centimeter  of  tissue.  It  is  also  important  to  know  the 
intensity  of  radiation  on  any  surface,  since  intensity  of  radiation  as  in 
all  spherical  dispersion,  varies  inversely  as  the*  square  of  the  distance 
from  the  source.  For  example,  the  intensity  of  radiation  from  radium 
i  millimeter  distant  from  a  i  millimeter  square  surface  is  625  times  that 
from  the  same  radium  upon  the  same  tissue  moved  25  millimeters 
away.  It  is  obvious  from  this  why  the  physiological  effect  of  the 
Gamma  ray  is  limited  to  distances  of  2  to  3  centimeters.  While  some 
Gamma  rays  act  at  greater  distance,  they  are  too  few  to  cause  evident 
results.  Some,  however,  claim  that  Gamma  rays  are  effectual  at 
greater  limits,  and  Bumm  believes  that  they  may  be  efficient  as  far  as 
4  centimeters. 

In  gynecology,  the  radium  is  generally  used  in  tubes,  either  as  a 
salt,  or  the  emanation.  It  is  inclosed  in  a  glass  capsule,  hermetically 
sealed,  which  cuts  off  the  Alpha  rays.  This,  in  turn,  is  covered  by  a 
similar  container  of  silver  or  platinum.  Other  filters  are  necessary  in 
order  to  cut  off  all  the  Beta  rays.  The  following  screens  are  supposed  to  suf- 
fice and  to  be  more  or  less  equal  to  each  other:  silver,  i  millimeter;  brass, 
1.3  millimeters;  steel,  1.4  millimeters;  lead,  1.5  to  2  millimeters;  gold, 
.6  millimeter;  and  platinum,  .5  millimeter.  It  is  probable  that  Beta 


268  PELVIC   NEOPLASMS 

rays,  when  passing  through  lead  niters,  break  up,  at  least  in  part,  and 
give  rise  to  more  secondary  rays  than  are  noted  with  other  screens. 
This  is  very  likely  to  cauterize  the  surrounding  tissues.  These  second- 
ary rays,  or  rayons  dc  Sagnac,  may  be  cut  off  by  inclosing  the  radium  con- 
tainers and  their  screens  in  a  black  rubber  tubing  or  hard  rubber  capsule 
whose  walls  are  2  to  3  millimeters  thick.  The  physiologic  effect  from  the 
rays  of  the  radio-active  substance  is  due  to  the  photo-electron  action,  that 
is,  the  liberation  of  negative  electrons  in  the  tissue.  Gamma  rays  produce 
at  least  part  of  their  effect  by  the  action  of  secondary  Beta  rays  which  result 
when  the  Gamma  rays  pass  through  cellular  tissue.  Since  the  primary 
Beta  rays  are  readily  absorbed,  they  are  useful  only  in  the  treatment  of 
superficial  growths  at  a  very  few  millimeters  thickness.  Since  the 
Gamma  rays  have  greater  penetrating  power,  they  produce  secondary 
Beta  rays  throughout  a  considerable  depth  of  tissue;  consequently 
they  are  useful  in  the  treatment  of  deep  lesions.  When  employing  the 
primary  Beta  ray,  the  Gamma  ray  is  negligible,  since  the  latter  are 
comparatively  few.  The  relative  proportion  of  Beta  and  Gamma  rays 
is  as  95  is  to  5.  When  we  desire  to  use  chiefly  the  Gamma  ray,  the 
Beta  ray  should  be  screened  off  by  metal  filters. 

Theoretically,  cancer  of  the  uterine  cervix  offers  a  splendid  oppor- 
tunity for  treatment  by  radiation,  since  the  radium  capsule  can  be 
inserted  in  the  cervix  in  the  very  center  of  the  carcinomatous  area 
when  it  will  radiate  through  the  center  of  the  pelvis.  The  pelvic  axis 
is  approximately  12  centimeters  in  its  diameter,  so  rays  6  centimeters 
in  length  would  completely  radiate  the  entire  pelvic  cavity.  Unfor- 
tunately, radium  in  ordinary  dosage  has  power  probably  to  kill  only  the 
cancer  cells  which  lie  2  or  3  centimeters  away.  Beyond  this,  there  is 
always  the  chance  that  cancer  cells  may  be  stimulated  to  activity  by 
rays  that  are  too  weak  or  too  few  to  kill.  The  bladder  and  rectum  may 
be  injured  by  treatment,  since  they  are  less  than  2  centimeters  distant 
from  the  cervical  canal  if  the  organs  are  empty.  Should  they  be  filled, 
they  are  much  closer  to  the  cervix.  In  order  to  avoid  injury,  they 
should  be  empty  and  held  as  far  away  from  the  cervix  as  is  possible. 
The  ureter  is  also  close  enough  to  sustain  injury. 

Unfortunately,  there  is  no  agreement  as  to  technic  or  dosage  in  the 
radium  treatment  of  cervical  cancers,  save  that  nearly  all  agree  that 
good  results  may  not  be  obtained  with  less  than  50  milligrams  or  milli- 
curies  of  radium.  There  are  two  schools,  one  believing  in  a  minimal 
dosage,  repeated  to  get  accumulative  effects  upon  the  cancer  cell  but 
subliminal  as  far  as  the  normal  tissues;  the  other  argues  that  the  best 
chance  of  attacking  the  cancer  is  by  massive  doses  at  the  first  treat- 
ment, although  few  longer  advise  the  use  of  as  much  as  a  gram  even 
for  a  short  time  except  rarely  for  cross-fire.  Both  schools  agree  that 
the  cervix  should  be  gently  dilated  or  burned  open  sufficiently  to  admit 


TREATMENT  OF  CANCER  OF  THE  CERVIX         269 

the  radium  capsule.    Nearly  all  have  abandoned  preliminary  cauteriza- 
tion or  curetting. 

Schmitz  is  the  advocate  of  the  small  doses  given  by  the  fractional 
method.  In  order  to  prevent  fistula  formation  which  is  almost  certain 
to  result  in  case  the  bladder  and  rectum  are  burned  to  a  serious  degree, 
he  gives  doses  which  he  believes  will  kill  the  cancer  cell  but  not  cause 
serious  injury  to  the  bladder  or  rectal  walls.  He  calculates  that  600 
milligram  element  hours  obtained  by  50  milligrams  of  radium  element 
maintained  in  position  for  twelve  hours,  will  cause  a  second  degree  burn 
of  these  organs  but  that  a  ten-hour  application  of  50  milligrams  of  the 
radium  element  or  500  milligram  element  hours  will  kill  the  cancer  cells 
but  not  injure  the  bladder  or  rectum.  He  believes  that  the  normal  cells 
of  these  organs  which  have  not  been  burned  to  the  second  degree 
recover  so  rapidly  that  they  will  withstand  another  similar  treatment 
after  an  interval  of  twenty-four  hours.  He  gives,  therefore,  a  treat- 
ment of  500  milligram  element  hours  daily  for  seven  successive  days, 
making  a  total  dosage  of  3,500  milligram  element  hours  which  he 
claims  will  cause  a  degeneration  of  all  carcinoma  cells  as  far  out  as  the 
bony  pelvic  wall.  To  the  latter  view,  we  cannot  subscribe,  since  there 
is  no  evidence  to  cause  us  to  believe  that  Gamma  rays  from  50  milli- 
grams of  radium  are  effective  at  more  than  3  or  4  centimeters.  Schmitz 
states  that  the  bladder  is  not  injured  by  his  method,  as  may  be  proved  by 
cystoscopic  examinations  made  at  ten-day  intervals  during  the  period 
the  radium  is  causing  changes,  that  is,  six  weeks.  He  uses  two  tubes  of 
25  milligrams,  of  the  radium  element  in  the  form  of  the  insoluble 
sulphate,  each  of  which  is  packed  in  a  cylinder  of  glass  of  an  outer 
diameter  of  2  millimeters  and  a  length  of  6  millimeters.  These  cylin- 
ders are,  in  turn,  inserted  in  silver  capsules  1.75  centimeters  long  with 
a  wall  0.5  millimeter  thick.  These  two  capsules  are  placed  tandem  in 
a  brass  tube  with  a  wall  0.7  millimeter  in  thickness.  The  total  metal 
screen  1.2  millimeters  thick  effectually  absorbs  Beta  radiation.  The 
Sagnac  rays  arising  in  the  metal  filter  are  absorbed  by  a  pure  black 
rubber  tubing  3  millimeters  thick  in  which  the  radium  carriers  are  con- 
tained when  they  are  placed  in  the  cervix.  The  vagina  should  be 
packed  with  gauze.  Schmitz  reports  his  results  in  1920,  but  since  none 
of  his  cases  have  stood  for  five  years,  they  cannot  be  considered  at  this 
time.  Preliminary  to  the  treatment  a  self-retaining  catheter  is  placed 
in  the  bladder  and  the  bowels  are  emptied  by  enema. 

The  other  view  is  represented  by  the  various  workers  in  the 
Memorial  Institute  in  the  city  of  New  York.  They  advise  that  3  tubes 
of  50  milligrams  emanation  properly  screened  in  a  manner  similar  to 
the  above  and  arranged  end  to  end,  be  placed  in  the  uterocervical  canal 
for  twenty  hours.  This  gives  a  cross-fire  on  the  upper  and  lower  mar- 
gins of  the  growth  as  well  as  direct  radiations  to  its  center.  Added 
cross-fire  is  obtained  by  placing  three  tubes  containing  the  same 


270  PELVIC  NEOPLASMS 

amount  of  emanations  against  the  cervical  ulcer.  They  are  held  in 
position  by  a  mold  of  dental  modeling  compound.  This  also  holds  the 
bladder  and  rectum  back  in  place.  The  treatment  is  given  for  20  hours, 
or  a  total  of  6,000  millicurie  hours,  which  is  obtained  by  3,000  millicurie 
hours  from  the  tubes  within  the  uterus  and  3,000  millicurie  hours 
placed  against  the  cervix. 

The  majority  of  workers  believe  that  there  is  no  advantage  in  using 
primary  Beta  rays  and  advise  a  screen  sufficiently  heavv  to  eliminate  all 
but  a  pure  Gamma  radiation.  Others,  however,  feel  that  the  hard 
Beta  rays  are  also  useful.  Local  treatment,  especially  for  small  can- 
cerous nodules  in  the  vagina,  may  be  obtained  from  a  number  of  Bare 
tubes  containing  2  to  5  millicuries  emanations  placed  about  I  centi- 
meter apart  directly  in  the  growth.  The  rectum  should  be  screened  by 
packing  the  vagina  with  gauze  to  prevent  the  reaction  which  otherwise 
would  occur. 

Some,  as  Turner,  have  advocated  large  doses  even  to  10,000  to 
15,000  millicurie  hours  for  a  primary  treatment.  Turner  claims  (1920) 
that  he  has  never  seen  bad  results  following  this  dosage.  The  treat- 
ment, however,  is  much  more  severe  than  that  given  by  the  American 
gynecologists  who  have  much  radium  at  their  disposal. 

Personally,  we  have  used  both  the  fractional  and  the  single  large- 
dose  methods.  For  two  years,  we  used  from  50  to  90  milligrams  of 
the  radium  element  placed  in  the  crater  and  maintained  in  position  long 
enough  to  give  a  primary  dose  of  1,200  to  1,500  milligram  hours.  The 
treatment  was  repeated  weekly  for  four  or  five  times.  The  results 
were  quite  as  satisfactory  as  those  yet  obtained  by  our  present  plan 
of  treating  with  150  to  200  millicuries  applied  in  several  tubes  placed  in 
the  cervix,  a  method  which  we  have  used  for  three  years.  We  have 
rejected  as  useless  augmenting  this  treatment  with  bare  needles  of  2 
to  5  millicurie  strength  in  the  margin  of  the  ulcers.  We  apply 
the  tubes  while  the  patient  is  anesthetized.  In  addition  to  the  glass 
capsule,  there  is  a  screen  of  0.5  millimeter  silver  and  1.2  millimeters  of 
brass  and  a  hard  rubber  container  3  millimeters  thick.  The  bladder 
and  rectum,  which  have  been  emptied  before  the  treatment,  are  held 
apart  by  the  dental  modeling  compound  which  fills  the  upper  part  of 
the  vagina.  Rubber  dam  and  gauze  are  also  used  occasionally  as  acces- 
sory filters.  Personally,  we  feel  that  it  is  often  dangerous  to  dilate  the 
cervix  for  the  introduction  of  the  radium.  We  feel  that  it  is  often  respon- 
sible for  metastases  and  the  spread  of  the  growth.  Occasionally  a 
cavity  may  be  made  with  a  cautery,  otherwise  the  radium  should  be 
placed  in  the  crater  unless  the  cervix  is  open  and  may  be  dilated  with- 
out trauma. 

Cross-fire. — Since  the  rays  from  moderate  doses  of  radium  applied 
directly  at  one  point  in  the  cervix  produce  satisfactory  results  through 
only  2  or  3  centimeters  of  tissue,  it  follows  that  supplementary  treat- 


TREATMENT  OF  CANCER  OF  THE  CERVIX        271 

ment  is  necessary  to  kill  the  cancerous  cells  that  lie  farther  out  in  the 
pelvis.  Some  sought  to  obtain  a  cross-fire  by  placing  radium  in  the 
rectum,  and  by  radiating  the  parametria  with  rays  filtered  through 
heavy  gold  screens  made  from  a  twenty-dollar  piece.  This  method  has 
been  abandoned.  Cross-fire  may  be  obtained  with  very  heavy  doses 
(a  gram  or  more)  of  emanations,  by  radiating  over  a  large  number  of 
different  areas  on  the  abdomen  and  pelvic  wall  to  the  parametric  wings 
and  the  glandular  areas.  This  method  has  its  basis  in  the  fact  that  all 
Gamma  rays  are  not  of  equal  length.  The  longer  rays  may  be  utilized,  if 
the  radium  is  applied  at  some  distance  from  the  skin,  and  the  weaker  and 
shorter  rays  are  cut  off  by  heavy  screens.  It  is  believed  that  when 
radium  is  applied  12  centimeters  from  the  skin  surface  that  80  per  cent 
of  the  Gamma  rays  will  reach  I  centimeter  below  the  surface ;  38.5  per 
cent  will  reach  5  centimeters  below;  and  approximately  20  per  cent  will 
reach  9  centimeters  below.  Therefore,  by  radiating  through  five 
portals  of  entry,  we  should  produce  at  the  depth  of  9  centimeters  the 
same  intensity  of  dosage  obtained  in  the 'tissues  under  one  of  the  five 
points  of  application.  The  practical  difficulty  is  occasioned  by  the  fact 
that  large  amounts  of  radium  are  necessary  to  accomplish  the  results, 
since  only  5  per  cent  of  the  heavy  rays  are  Gamma  rays,  and,  of  these, 
only  a  few  are  sufficiently  strong  to  cause  proper  reaction  9  centimeters 
down  in  the  pelvis. 

Amreich,  in  1921,  called  attention  to  the  fact  that  the  uterus  and 
broad  ligament  parametric  structures  lie  like  a  butterfly  within  the 
pelvis.  Seeking  to  reach  the  farthest  tip  of  parametric  wings,  he  intro- 
duces radium  tubes  through  a  tunnel  in  the  obturator  foramen  on  both 
sides.  This  technic  has  also  been  used  by  Nordentoft,  in  1921,  for 
which  he  claims  many  advantages,  since  the  parametria  and  sacro- 
uterine  ligaments  are  reached  from  the  side.  On  paper,  it  seems  like  risky 
treatment. 

Others  are  turning  their  attention  to  the  X-ray  as  a  means  of  cross-fire 
in  the  parametrium.  Since  the  introduction  of  the  Coolidge  tube,  the 
X-ray  has  been  used  again  for  the  treatment  of  cancer,  although  only 
supplementary  to  radium  or  to  operation.  Few  believe  that  the  X-ray 
is  a  rational  procedure  as  a  primary  measure.  Moreover,  unless  the 
treatment  is  systematically  and  judiciously  used,  it  is  likely  to  be  not 
only  a  waste  of  time,  but  possibly  harmful  as  well,  since  it  may  stim- 
ulate cell  proliferation,  as  do  minimal  doses  of  radium.  Large  doses 
may,  of  course,  cause  serious  burns.  In  an  individual  of  ordinary  build, 
a  maximum  dose  of  deeply  penetrating  and  carefully  filtered  rays  must 
be  introduced  through  seven  to  ten  ports  of  entry  at  the  skin  surface  in 
order  to  be  at  all  destructive  to  cancer  cells  in  the  pelvis.  In  the  event 
of  metastases,  there  should  be  thirty  to  fifty  such  treatments  made 
from  every  possible  direction  into  the  pelvis  (Pancoast).  Such  ex- 
tensive and  intensive  treatment  is  bound  to  exert  some  effect  upon  the 


272  PELVIC   NEOPLASMS 

intestinal  tract  and  may  even  do  some  harm  occasionally,  although  this 
is  not  to  be  considered  in  comparison  with  the  harm  which  results  from 
the  growth.  The  patient  should  be  fully  acquainted  with  the  situation, 
however,  since  suits  arising  from  X-ray  burns  are  unfortunately  com- 
mon. Personally,  we  have  not  seen  good  results  following  cross-fire 
with  X-ray,  even  where  it  had  been  directly  applied  through  the 
vagina.  Skinner,  in  1920,  claims  that  cases  which  early  exhibit  a  tan- 
ning of  the  skin  as  the  result  of  the  X-ray  treatment  seem  to  offer  the 
best  prognosis.  He  states  that  even  variations  in  technic  did  not  pro- 
duce tanning  in  the  cases  that  were  losing  ground. 

Complications. — Patients  occasionally  present  some  fever  and  have 
nausea  and  vomiting  shortly  following  radium  treatment.  In  our 
experience,  this  has  been  a  very  rare  event.  More  serious  is  the  pain 
which  occasionally  follows  treatment  in  spite  of  every  precaution.  We 
have  noted  this,  resulting  for  the  most  part,  from  burns  of  the  rectum. 
In  a  small  per  cent  of  cases,  notwithstanding  every  possible  care  in  pro- 
tecting the  rectum,  a  very  acute  proctitis  follows.  Mucus  and  blood 
may  be  discharged,  and  the  pain  may  be  so  severe  as  to  require  hyp- 
notics. It  may  result  even  though  the  radium  is  completely  inclosed 
within  the  cervical  canal.  In  a  majority  of  cases,  a  mucilaginous  sus- 
pension of  bismuth  subnitrate  by  rectal  injection  may  be  quite  suf- 
ficient to  soothe  the  pain.  It  may,  however,  be  so  severe  as  to  require 
opium.  We  are  particularly  impressed  with  the  fact  that  burns  either 
of  the  rectum  or  the  fibrosis  resulting  after  massive  treatment  of  the 
uterosacral  ligaments  may,  in  the  process  of  contraction,  be  sufficient 
even  to  cause  intestinal  obstruction.  The  majority  of  men  agree  that 
large  initial  doses  of  radium  are  likely  to  cause  pain  from  compression 
of  the  nerves  by  the  resulting  cicatrix.  Others  state  that  particularly 
heavy  screening  sufficient  to  exclude  all  the  Beta  rays  will  do  much  to 
avoid  pain.  However,  in  a  series  of  58  inoperable  cervical  cancers 
treated  by  us  with  divided  doses,  each  of  1,200  to  1,500  milligram 
hours,  pain  was  conspicuous  by  its  absence,  except  in  the  few  cases  in 
which  fistulae  developed. 

Fistulae  form  a  very  distressing  complication.  Many,  but  by  no 
means  all,  may  be  charged  to  the  radium,  since  they  may  well  result 
from  the  breaking  down  of  cancerous  strands  which  have  invaded  the 
bladder  or  rectal  walls.  While  it  is  perfectly  certain  that  this  terminal 
event  will  occur  in  a  large  number  of  cancer  patients  which  are  not 
treated  with  radium,  we  believe  at  the  same  time  that  a  man  beginning 
radium  work  will  see  more  fistulae  early  in  the  series  than  he  will  later. 
Pyometra  is  a  common  sequence  and  may  best  be  treated  by  sounding 
the  uterus  occasionally  with  rubber  or  metal  sounds. 

Results  of  Radium  Treatment. — The  exact  value  of  radium  in  the 
treatment  of  uterine  cancers  has  not  yet  been  definitely  ascertained. 
Nearly  all  agree,  however,  that  it  is  not  best  adapted  for  the  treatment 


TREATMENT  OF  CANCER  OF  THE  CERVIX         273 

of  cancers  of  the  uterine  body  and  fundus,  since  these  cases  do  better 
with  operation.  It  is  difficult  to  clearly  define  the  position  of  radium 
as  a  therapeutic  measure  in  cancers  of  the  uterine  cervix  because  of  the 
variations  in  the  type  of  tumor,  the  amount  of  involvement,  the  varia- 
tions in  dosage,  the  duration  of  the  application,  the  technic  and  other 
variables  which  cannot  yet  be  accurately  controlled.  All  agree  that 
soft,  medullary  growths  are  more  easily  influenced  than  harder 
growths  and  adenocarcinomata.  There  is  no  .doubt,  however,  that 
radium  has  a  palliative  action  in  the  treatment  of  inoperable  tumors 
which  is  not  equaled  by  any  other  type  of  treatment  at  the  present 
time.  It  may  also  be  better  than  surgery  for  border-line  cases.  Some 
have  become  most  enthusiastic  about  its  possibilities  and  would  extend 
its  use  to  operable  cervical  growths,  and  thus  supplant  surgery.  Yet 
the  careful  student  will  remember  that  the  status  of  surgery  in  cervical 
cancer  is  only  now  being  clearly  defined  after  the  observation  of  many 
thousands  of  cases  which  were  treated  by  truly  radical  operations  dur- 
ing the  past  twenty  years.  Before  the  results  of  radium  can  be  com- 
pared with  those  of  surgery,  it  is  necessary  that  all  cases  treated  by 
radium  should  be  followed  in  proper  classifications  for  the  five-year 
period  just  as  has  been  done  in  surgery.  At  the  present  time,  there 
are  few  statistics  which  have  met  this  requirement.  The  present  liter- 
ature fairly  teems  with  the  repor.ts  of  immediate  results  of  radium 
treatment.  Nearly  every  radium  institute  in  the  country  is  sending 
forth  papers  recording  cases  which  have  been  clinically  cured  for 
periods  of  three  months,  six  months,  a  year,  or  a  year  and  a  half. 
This,  of  course,  may  mean  nothing  save  that  the  ulcer  has  temporarily 
disappeared.  The  sane  man  will  postpone  his  judgment  until  sufficient 
data  has  accumulated  upon  which  we  may  form  an  opinion  based  on 
facts,  and  not  on  hope.  The  majority  of  men  writing  from  the  stand- 
point of  radium  urge  that  this  treatment  is  practically  without  mor- 
tality as  if  this  were  the  most  important  consideration.  While  no  sur- 
geon is  especially  desirous  of  doing  operations  which  are  attended 
with  10  per  cent  to  30  per  cent  mortality,  he  is  at  least  interested  in 
the  permanent  cure.  The  majority  of  writers  lose  sight  of  the  fact 
that  cervical  cancers  invariably  kill  unless  the  growth  is  completely 
eradicated.  Surgical  literature  clearly  indicates  that  only  early  growths 
permit  of  cure  save  in  very  exceptional  instances,  since  the  final  results 
of  extensive  operations  on  border-line  cases  as  a  class  are  not  good. 
Consequently  there  is  a  broad  field  for  radium  in  the  class  of  cases 
where  surgery  fails,  without  extending  it  to  other  than  the  operable 
cases,  which  by  reason  of  systemic  disease  cannot  undergo  operation. 
Few  thinking  individuals  afflicted  with  cancer  would  deliberately 
choose  to  prolong  their  lives  for  a  very  few  years,  if  there  was  every 
certainty  that  they  would  finally  succumb  to  cancer,  provided  they 
had  a  reasonable  chance  of  permanent  cure  by  operation  without  dis- 


274  PELVIC   NEOPLASMS 

tressing  sequelae.  The  clear  fact  that  stands  out  in  the  literature  of 
cancer  of  the  cervix  is  that  approximately  50  per  cent  of  operable 
growths  may  be  permanently  cured  by  surgical  measures.  The  facts 
are  not  yet  known  concerning  radium. 

Properly  speaking,  we  should  consider  the  results  of  the  radium 
treatment  of  cervical  carcinoma  in  the  four  stages,  that  is,  the  operable, 
border-line,  inoperable,  and  recurrent  cases. 

Treatment  of  Operable  Cervical  Carcinoma  by  Radium. — The  Ger- 
mans have  long  been  enthusiastic  on  the  value  of  radiotherapy,  but 
there  have  been  no  available  statistics  until  the  last  year.  In  1919, 
Bumm  presented  his  results  between  the  years  1913  and  1915  sum- 
marized as  follows:  during  the  year  1913,  he  had  14  operable  cervical 
carcinomata  which  he  radiated  (radium  or  mesothorium)  and  did  not 
operate.  Of  these,  28.5  per  cent  have  remained  cured  for  fully  five 
years.  In  1914,  there  were  20  operable  cases  which  were  radiated  and 
not  operated.  Of  these,  20  per  cent  remained  cured  between  four  and 
five  years.  In  1915,  out  of  40  operable  cervical  carcinoma,  55  per  Cent 
remained  cured  for  a  period  between  three  and  four  years.  The  oper- 
ative mortality  for  cancer  of  the  cervix  treated  by  radical  operation 
was  13.8  per  cent  for  203  cases  treated  between  1911  and  1915.  Of 
157  cases  operated  between  1911  and  1913  in  his  clinic,  77  were  well, 
after  periods  from  six  to  eight  yeajs  or  a  cure  of  49  per  cent.  Bumm 
emphasized  the  fact  that  the  percentage  of  cures  after  radium  in  oper- 
able and  border-line  cases  of  carcinoma  of  the  cervix  was  one-third 
less  than  that  obtained  by  operation  at  the  end  of  six  years.  When 
the  cases  are  only  observed  for  a  period  of  three  years  (1915  series), 
the  results  of  radiation  surpass  those  of  operation  in  cervical  cancer, 
since  55  per  cent  of  the  operable  cases  treated  by  radium  remained 
well.  It  has  been  stated  that  if  there  are  recurrences  following  radium 
they  will  occur  within  the  first  year,  if  they  are  going  to  recur  at  all. 
Bumm,  however,  has  had  many  instances  of  recurrence  in  the  second 
and  third  years  after  radium.  As  a  result  of  his  investigation,  he  be- 
lieves that  operation  will  give  better  results  than  radium,  when  the 
cases  are  early  and  the  patient  is  in.  reasonably  good  physical  con- 
dition. Bailey  and  Quimby,  in  1922,  report  one  operable  case  (a  very 
early  growth)  which  was  indicated  and  not  operated  and  which  re- 
mained cured  for  five  years. 

Treatment  of  Border-line  Carcinoma  by  Radium. — There  is  nearly 
universal  agreement  that  this  type  of  case  can  be  better  treated  with 
radium  than  by  surgery,  since  the  latter  rarely  cures  more  than  10  per 
cent  to  15  per  cent  of  the  cases  in  which  it  is  attempted.  While  some, 
as  Bumm,  have  obtained  distinctly  favorable  results  with  surgery,  the 
majority  have  not  done  so.  There  is  extensive  involvement  of  the 
cervix  in  these  cases  and  the  growth  has  usually  extended  to  the 
vagina  and  parametrium  so  that  the  uterus  is  fixed,  at  least  on  one 


TREATMENT  OF  CANCER  OF  THE  CERVIX         275 

side.  With  a  properly  adjusted  and  properly  screened  dosage,  radium 
does  far  more  than  may  be  accomplished  by  surgery  and  without 
appreciable  mortality.  On  the  contrary,  the  mortality  following  oper- 
ation is  considerable  in  this  group  of  cases.  Not  every  border-line 
case,  however,  reacts  favorably  to  radium.  Occasionally,  we  have  seen 
cases  which  formerly  we  would  have  operated  show  no  response  what- 
ever to  radiation.  Since  the  ulcer  alone  presented,  the  original  type 
of  the  growth  could  not  be  determined. 

Bumm;  during  the  years  1913,  1914,  and  1915,  respectively,  treated 
22,  21,  and  38  cases  of  border-line  cervical  carcinoma  with  radium  only, 
obtaining  the  following  percentage  of  cures  at  the  time  of  his  report 
printed  in  1919,  but  prepared  in  1918:  23  per  cent  for  five  years;  19 
per  cent  between  four  and  rive  years;  and  39  per  cent  between 
three  and  four  years. 

Treatment  of  Irioperable  Carcinoma. — In  inoperable  cases,  excel- 
lent palliative  results  have  been  obtained  by  radium,  with  the  control 
of  hemorrhage,  discharge  and  the  retrogression  of  the  growth.  Occa- 
sionally, however,  particularly  in  the  advanced  cases  in  which  death 
is  a  matter  of  a  few  months,  the  treatment  seems  to  aggravate  the 
condition  and  bring  on  the  end  sooner.  There  are  numerous  instances 
of  necrotic  cauliflower  cervical  cancers  which  project  into  the  vaginal 
canal,  which  have  produced  a  severe  anemia,  toxemia,  and  even  ca- 
chexia  because  of  hemorrhage  and  infection.  In  many  cases,  radiation 
of  these  growths  has  promptly  stopped  the  bleeding  and  restored  the 
patient  to  a  normal  condition  for  a  considerable  period  of  time.  We 
have  seen  a  number  of  this  type  who  remained  well  for  two  or  more 
years  before  they  succumbed  to  the  disease.  Some  cases  with  soft, 
medullary  growths  even  appear  as  if  they  might  remain  cured.  The 
difficulty  in  the  treatment  of  these  cases  is  that  the  growth  has  ap- 
proached closely  the  rectum  or  bladder.  Radium,  therefore,  is  very 
likely  to  produce  a  fistula  in  event  of  massive  doses.  If  minimal  doses 
are  given,  it  seems  reasonable  to  believe  that  the  ulcer  will  be  cleaned 
up,  but  that  the  tumor  will  proceed  to  grow  along  its  advancing  edges 
on  the  intra-abdominal  side.  The  most  that  can  be  expected  in  the 
inoperable  growths  is  that  radium  will  produce  a  local  cure,  that  is, 
a  cure  of  the  ulcer,  and  arrest  of  the  hemorrhage  and  infection.  We 
often  overlook  the  fact  that  the  symptoms  of  cancer,  before  the  advent 
of  pain  and  cachexia,  are  due  to  the  infected  ulcer.  Curing  the  ulcer, 
therefore,  produces  remarkable  results  in  the  general  well-being  of 
the  patient.  Unfortunately,  it  does  not  follow  that  the  disease  is 
arrested  when  the  ulcer  has  been  cured. 

Bumm  treated  42  cases  of  inoperable  carcinoma  by  radium  in  1913. 
In  1919,  2  were  still  living,  or  4.7  per  cent  of  cure.  During  1914,  he  had 
36  inoperable  cases  with  2  four-  to  five-year  cures,  or  5.5  per  cent. 


276  PELVIC   NEOPLASMS 

In  1915,  there  were  49  cases.  At  the  time  of  his  report,  in  1919,  there 
were  5,  or  5  per  cent,  still  classed  as  cured  for  three 'to  four  years. 

There  is  as  yet  no  other  well-controlled  series  which  may  be  com- 
pared with  Bumm's  reports  in  which  the  cases  are  grouped  so  that 
they  may  permit  of  comparison  with  others,  with  the  exception  of 
Bailey's  smaller  series  which  appeared  in  1922.  Within  the  last  year, 
however,  there  have  been  a  number  of  reports  of  small  series  of  cases 
which  have  remained  cured  for  five  years.  Heyman  reports,  in  1920, 
26  cases  from  Scandinavia  that  were  treated  with  radium  in  1914. 
Of  these,  7  remained  cured  in  1919.  Unfortunately,  he  did  not  state 
the  type  of  cancers  nor  give  other  data  save  that  85  per  cent  of  this 
series  together  with  40  cases  which  were  observed  in  1915  and  had 
not  yet  stood  for  five  years,  were  inoperable.  Hansen,  in  Copenhagen, 
in  1920,  reports  27.3  per  cent  of  cure  for  a  five-year  period  in  66  cases, 
most  of  which  were  inoperable.  Recasens,  in  Madrid,  in  1919,  claims 
several  cases,  which  were  supposed  to  have  been  inoperable,  remained 
free  from  recurrence  for  five  years.  There  are  no  reports  of  five-year 
cures  in  America,  save  for  the  few  cases  noted  by  Ransohoff  and  Clark. 
Ransohoff,  in  1920,  reports  I  operable  case  which  remained  free  from 
recurrence  after  radiation  for  five  years  and  i  operable  and  i  inoperable 
case  which  were  also  without  recurrence  at  the  end  of  four  and  a  half 
years,  although  the  last  case  presented  a  rectovaginal  fistula.  Clark, 
in  1920,  reports  I  of  9  inoperable  cervical  carcinomata  which  remained 
free  from  recurrence,  after  radiation,  for  five  years.  Bailey  reports 
(1922)  that  none  of  his  15  cases  of  advanced  cervical  cancer,  treated 
in  1915*  survived  five  years.  Two  of  the  15  cases  which  were  treated  by 
the  Percy  heat  method,  and  then  radiated,  survived  five'  years.  Several 
cases,  however,  had  a  slough  of  the  pelvic  tissues  in  consequence  of  the 
ligation  of  the  uterine  vessels. 

There  are  numerous  observers  who  report  cases  cured  for  four 
years,  yet  these  cannot  be  considered  at  the  present  time,  since  they 
have  not  yet  stood  for  the  five-year  period.  We  have  quoted  Bumm's 
four-year  cases  merely,  since  they  admit  of  comparison  with  his  five- 
year  series. 

Treatment  of  Recurrences  Following  Operation. — The  treatment 
of  growths  which  have  recurred  after  operation  is  nearly  uniformly 
unsatisfactory.  In  addition  to  the  fact  that  cures  are  most  unlikely, 
there  is  a  real  danger  of  injuring  the  bladder  and  rectum  by  radiation, 
since  these  structures  have  been  brought  close  together  after  the  uterus 
has  been  removed.  When  cancer  cells  are  left  in  the  vaginal  wall, 
they  may  be  killed  witR  radium,  yet  if  there  are  cancer  masses  in  the 
parametrium,  there  is  less  chance  of  their  control.  None  of  the  26 
cases  treated  by  us  survived  two  years  after  the  advent  of  recurrence. 
The  majority  of  this  group  were  operated  by  others,  chiefly  by  incom- 
plete vaginal  hysterectomies.  Some,  however,  followed  Wertheim 


277 

operations  which  we  ourselves  performed  and  which  we  felt  were  truly 
radical  at  the  time  of  operation.  Nearly  all  presented  large  recur- 
rences in  the  pelvis.  Schmitz,  however,  has  i  case  in  his  series 
of  50  such  cases  that  is  still  living  three  years  and  nine  months;  also 
2.  cases  that  lived  for  more  than  two  years  after  the  beginning  of  treat- 
ment. Bumm,  in  1913,  treated  25  recurrences  after  operation.  None 
were  living  in  1918.  He  had  37  cases  in  1914,  of  which  5,  or  13.5 
per  cent,  were  living  between  four  and  five  years  at  the  time  of  his 
report.  There  were  12  cases  in  his  series  in  1915,  of  whom  none 
remained  alive  at  the  end  of  three  years. 

The  Question  of  Operating  Cases  which  Appear  to  Have  Been 
Made  Operable  by  Radium  Treatment. — There  is  as  yet  no  unanimity 
of  opinion  concerning  the  value  of  operating  this  type  of  case.  The 
majority  believe  that  it  should  not  be  done  because  of  the  chance  that 
carcinoma  cells  which  have  been  encompassed  by  scar  tissue  may 
escape  during  the  operation  and  resume  their  growth.  Clark,  espe- 
cially, urges  that  patients  which  appear  to  have  been  cured  by  radium 
should  be  let  alone.  Schmitz,  and  others,  agree  with  him.  Some  state 
to  the  contrary  that  if  the  cells  which  remain  alive  in  the  midst  of 
connective  tissues  are  not  removed,  they  will  begin  to  grow  again,  and 
finally  break  through  their  fibrous  capsule  and  subsequently  kill.  In 
this  connection,  we  should  recall  the  experience  of  Bumm,  and  others, 
which  shows  that,  even  though  the  cancer  cells  in  the  uterus  have 
been  killed  by  radiation,  the  lymphatic  glands  may  contain  cancer  cells 
which  are  alive,  and  which  can  be  removed  only  by  surgical  procedure. 
Practically,  however,  operation  is  extremely  difficult  and  it  may  be 
well-nigh  impossible  to  liberate  the  ureters  from  the  dense  mass  of 
fibrous  tissue  which  has  resulted  from  the  radiation.  The  glands, 
moreover,  may  be  so  firmly  attached  to  the  vessel  wall  that  an  attempt 
to  remove  them  will  be  followed  by  serious  consequences.  Personally, 
we  have  operated  6  cases  in  which  inoperable  growths  were  apparently 
made  operable  by  radiation.  As  a  result  of  this  experience,  we  believe 
in  the  policy  of  noninterference.  One  case,  especially,  was  extremely 
interesting.  The  patient  had  a  large  mass  which  nearly  filled  the 
pelvis  at  the  time  of  the  first  treatment.  Within  three  months,  it  had 
disappeared  almost  completely  following  five  weekly  treatments,  each 
of  1,200  milligram  hours.  We  then  attempted  a  removal.  The  para- 
metria  were  dense  and  brawny.  Both  ureters  had  been  converted  into 
hydro-ureters.  The  first  freed  without  difficulty.  In  attempting  to 
free  the  second  hydro-ureter,  the  uterus  was  torn  across  the  stump 
of  the  cervix.  One  hundred  milligrams  of  radium  was  placed  in  the 
cavity,  and  the  peritoneal  cover  was  completed.  The  radium  was  left 
in  place  for  twelve  'hours.  In  spite  of  this  astonishing  accident,  the 
patient  is  living  three  and  a  half  years  after.  Degenerated  cancer  cells 


278  PELVIC  NEOPLASMS 

were  found  in  veins  in  the  margins  of  the  cervix.    The  rest  of  the  tissue 
was  fibrosed. 

Radium  Treatment  Preliminary  to  Operation. — The  impression  is 
constantly  growing  that  radium  may  be  safely  used  as  a  preliminary 
measure  before  the  operation  of  early  cases.  Since  dense  adhesions 
result  four  or  five  weeks  after  radiation,  the  majority  of  men  operate 
ten  days  after  radium  at  a  time  when  the  carcinoma  cells  are  breaking 
down  and  there  is  penetration  by  the  lymphocytes.  Edema  is  still 
present.  Theoretically,  this  should  reduce  the  chances  that  carcinoma 
cells  may  be  detached  from  their  implantation  and  escape  into  the 
lymphatics  during  the  operative  removal. 


LITERATURE 

BAILEY.    Am.  J.  Obst.    1919.    80:  30. 

BAILEY  AND  QUIMBY.    Am.  J.  Obst.     1922.    2:  117. 

BUMM.    Zentralbl.  f.  Gynak.     1913.    37 :  I. 

Zentralbl.  f.  Gynak.     1919.     I :  r. 

Berl.  klin.  Wchnschr.     1914.     51:  193. 
CLARK.     Surg.,  Gynec.  &  Obst.    1918.    26:  619. 
COBB.    J.  Am.  M.  Ass.     1920.    74:  14. 
DICKINSON.    Am.  J.  Obst.     1917.     75:  737. 
DOEDERLEIN-MEYER.    Monatschr.  f.  Geburtsh.     1911.    33:701. 
EDEN-LOCKYER.     Syst.  Gynec.     1917.     2. 
FRANZ.    Arch.  f.  Gynak.     1912.    97:  380. 
HOFMEIER.     Ztschr.  f.  Geburtsh.     1911.     69:  543. 
JACOBSON.    J.  Am.  M.  Ass.     1911.     56:  96. 
KRONIG.    Miinchen.  med.  Wchnschr.     1914.    61  :  1715. 
MARTIN.    Zentralbl.  f.  Gynak.     1909.    28:976. 
MEYER.    Monatschr.  f.  Geburtsh.     1911.     33:  701. 
NEEL  (KELLY).    Surg.  Gynec.  &  Obst.    1913.     16:  293. 
PERCY.    Am.  J.  Obst.     1918.    77:  93. 
PETERSON.     Surg.,  Gynec.  &  Obst.     1912.     15:  135. 
RANSOHOFF.   J.  Am.  M.  Ass.    1920.    74:163. 
RIES.    Ztschr.  f.  Geburtsh.     1895.    32  :  266. 
SCHAUTA.    Monatschr.  f.  Geburtsh.     1911.    33:680. 

Zentralbl.  f.  Gynak.     1914.    38:  961. 
TAUSSIG.    Surg.  Gynec.  &  Obst.     1912.     15:  147. 
THORN.     Gynak.  Rundschau.     1911.     5:601. 
VAN  OTT.    Monatschr.  f.  Geburtsh.     1912.    35:  715. 
WEIBEL.     Surg.,  Gynec.  &  Obst.     1913.     16:  254. 


CHAPTER  X 


Carcinoma  —  Classification  —  Frequency — Etiology — Age — Appearance  and  form — Micro- 
scopic appearance  —  Method  of  growth  —  Metastasis  —  Complications  —  Symptoms  — 
Diagnosis — Treatment — Comparison  of  types  of  operation — Radium.  Sarcoma  of  the 
Uterus  —  Frequency — Etiology — Age — Location  of  tumor  —  Classification  —  Types  — 
Histology — Sarcoma  of  the  cervix — Types — Mixed  forms — Method  of  extension — 
Complications — Symptoms — Hemorrhage — Pain — Leukorrhea — Sarcoma  of  the  uter- 
ine wall — Sarcoma  of  endometrium — Sarcoma  of  cervix — Diagnosis — Prognosis — 
Treatment. 

CARCINOMA  OF  THE  UTERINE  BODY 

Carcinomata  of  the  uterine  body  are  practically  without  exception 
adenocarcinomata.  They  are  nearly  all  primary.  In  marked  contrast 
to  carcinoma  of  the  cervix,  carcinoma  of  the  body  of  the  uterus  gives 
symptoms  early,  does  not  tend  to  invade  the  underlying  structures 
until  the  symptoms  are  well  established,  and  does  not  give  rise  to 
metastases,  as  a  rule,  until  late  in  its  course.  For  these  reasons,  the 
disease  may  be  cured  by  hysterectomy  in  the  very  great  majority  of 
cases. 

Classification. — The  adenocarcinoma  may  arise  from  the  surface 
epithelium  of  the  endometrium,  or  from  the  glands,  or  may  develop 
in  the  same  tissues  on  uterine  polyps.  Just  as  in  carcinoma  of  the 
cervix,  there  may  be  everting  or  inverting  types.  A  few  cases  of 
squamous  cell  carcinoma  of  the  body  of  the  uterus  have  been  reported 
as  primary  growths.  This  condition  is  at  least  extremely  rare  and 
there  is  considerable  controversy  in  regard  to  it.  This  phase  of  the 
question  has  been  discussed  on  page  187.  Some  authors  have  divided 
carcinoma  of  the  endometrium  into  the  headings,  columnar  carcinoma, 
adenocarcinoma,  and  malignant  adenoma.  This  classification  will  not 
be  followed.  The  tumors  are  usually  primary,  although  they  may 
develop  from  metastases  from  growths  primary  in  other  parts  of  the 
uterus  or  from  contiguous  organs. 

Frequency. — With  more  exact  methods  of  observation,  the  disease 
has  been  found  more  frequently  than  was  first  indicated  by  the  litera- 
ture, although  it  varies  considerably  in  different  localities.  In  America, 
Cullen  found  that  25  per  cent  of  176  cancers  of  the  uterus  were  cancers 
of  the  uterine  body.  Peterson  found  16  per  cent  in  107  cases.  Baldy 

279 


28o  PELVIC   NEOPLASMS 

saw  only  24  cancers  of  the  uterine  body  in  sixteen  years  in  Philadelphia. 
In  a  series  of  98  uterine  cancers,  we  found  8  that  were  cancers  of  the 
uterine  body.  Roger  Williams,  in  Great  Britain,  found  only  2  cases  in 
100  cancers  of  the  uterus;  Wilson,  5.6  per  cent  of  his  series  in  Birming- 
ham. In  Germany,  Scheib  in  1909  found  27  cancers  of  the  uterine  body 
in  531  cancers  of  the  uterus  (5  per  cent)  ;  Aulhorn,  in  1910,  reported  5 
per  cent  in  a  series  of  641  cancers  of  the  uterus ;  Knauer  found  2  per  cent 
in  1,374  uterine  cancers ;  Krukenberg,  6.7  per  cent  in  848  cases  ;  Freund, 
Sr.,  7.9  per  cent  in  227  cases;  Kuestner,  9.4  per  cent  in  234  cases; 
Offergeld,  5  per  cent  of  uterine  cancers;  Hofmeier,  3.4  per  cent  of  812 
cancers;  Winter,  12  per  cent  in  210  cancers.  Of  the  uterine  cancers 
which  have  been  removed  by  operation,  Rouffart  found  that  10  per 
cent  were  cancers  of  the  uterine  body;  Repen,  7  per  cent;  Blau,  12 
per  cent;  Waldstein,  16  per  cent;  Meyer,  17  per  cent.  Wertheim  saw 
only  70  cases  as  opposed  to  more  than  1,500  cancers  of  the  cervix  (4.5 
per  cent).  Sixty-seven  of  these  were  operated  while  only  714  of 
cancers  of  the  cervix  were  operated.  The  relative  frequency  of  uterine 
cancers  which  were  operated  in  Wertheim's  clinic  was  9.5  cancers  of 
the  uterine  body  to  100  cancers  of  the  cervix. 

Etiology. — The  etiology  is  not  known.  The  various  theories  which 
have  been  advanced  for  cancer  in  general  have  been  advocated  for 
uterine  cancer.  These  are  reviewed  on  page  177.  The  predisposing 
causes  are  not  identical  with  those  of  cervical  carcinoma.  Thus,  preg- 
nancy does  not  seem  to  be  a  predisposing  factor  in  cancer  of  the  uterine 
body,  although  there  is  no  doubt  that  it  is  such  in  cancer  of  the  cervix. 
Cancer  of  the  uterine  body  often  occurs  in  nulliparous  \vomen.  Gusse- 
row  emphasized  this  in  his  early  reports.  Weibel  found  that  one- 
fourth  of  Wertheim's  cases  had  never  been  pregnant  and  that  20  per 
cent  had  been  pregnant  but  once.  Wilson  states  that  there  was  an 
average  of  two  and  a  half  pregnancies  to  each  of  his  56  cases,  which 
was  far  less  than  that  found  in  his  series  of  cancer  of  the  cervix.  In 
about  one-third  of  his  cases,  the  last  pregnancy  had  been  twenty  or 
more  years  before  the  development  of  symptoms;  the  interval  was 
between  forty  and  fifty  years  in  several  cases.  The  frequent  asso- 
ciation of  adenocarcinoma  of  the  body  of  the  uterus  with  fibroids  has 
been  emphasized,  and  it  is  possible  that  the  changes  in  the  endometritim 
induced  by  fibroids  may  occasionally  be  responsible  for  the  malignant 
condition. 

Age. — Carcinoma  of  the  body  of  the  uterus  usually  occurs  after 
the  menopause.  Roger  Williams,  analyzing  500  cases,  found  more 
cases  between  fifty  and  sixty  years  than  in  any  other  decade.  Wilson, 
in  tabulating  his  56  cases,  found  that  the  youngest  was  forty-seven 
years  and  the  oldest  seventy-six,  while  49  cases  occurred  between 
forty-five  and  sixty-five.  While  the  disease  may  occur  in  women  who 
are  comparatively  young,  it  does  not  do  so  as  frequently  as  cancer  of 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  281 

the  cervix.  Wertheim's  youngest  case  was  thirty-two  years.  He  had 
only  one  other  under  forty.  Yet  Reipen  reported  one  of  twenty  years, 
and  Engelhorn  one  of  twenty-two  years. 

Appearance  and  Form. — Adenocarcinoma  may  commence  at  any 
point  within  the  uterine  cavity.  It  rarely  begins  at  any  one  definite 
point,  and  even  the  very  earliest  stages  usually  show  a  rather  wide- 
spread development  of  the  disease.  On  sectioning  the  uterus,  the  well- 
advanced  growth  presents  a  soft,  fairly  homogeneous  whitish-yellow 
mass  which  stands  out  in  sharp  contrast  to  the  surrounding  muscle. 
Necrotic  areas  are  not  uncommon.  On  closer  inspection,  at  the  edges 
of  the  growth  the  mass  will  be  found  to  consist  of  delicate,  fingerlike 
processes  which  give  it  a  somewhat  shaggy  appearance.  The  older 
polypoid  processes  may  appear  as  a  branched  or  treelike  growth  con- 
sisting of  several  main  stems  and  numerous  offshoots,  and  with  delicate, 
fingerlike  processes  as  terminal  branches.  The  tumor  is  confined 
almost  invariably  to  the  body  of  the  uterus,  and  rarely  extends  into 
the  cervix. 

Carcinoma  which  develops  from  the  surface  epithelium  presents,  at 
first,  little  mounds  of  cells  developing  on  the  surface.  They  are  com- 
posed of  two  or  three,  or  even  more,  layers  of  epithelial  cells  which, 
apart  from  occasional  swelling  of  their  nuclei,  show  nothing  abnormal. 
They  are  devoid  of  a  supporting  stroma.  Presently,  the  little  out- 
growths become  longer  and  the  stroma  develops  from  the  underlying 
tissue,  carrying  with  it  loops  of  blood  vessels.  The  stroma  varies  con- 
siderably, being  scanty  in  some  cases  and  extremely  well-developed  in 
others.  The  epithelial  cells  are  usually  much  enlarged  and  irregular. 
The  nuclei  are  large,  irregular,  and  stained  deeply.  Occasionally,  the 
epithelium  covering  the  fingerlike  processes  proliferates  and  forms 
glandlike  structures.  The  shape  of  the  polypoid  processes  varies  con- 
siderably ;  sometimes  they  have  crenated  margins  and  are  covered  by 
many  layers  of  epithelial  cells  of  fairly  uniform  size;  occasionally  they 
are  finely  branched  and  the  terminal  offshoots  consist  entirely  of  epi- 
thelial threads;  often  the  margins  of  the  papillae  are  crenated,  showing 
depressions  or  bays  along  their  edges.  Polymorphic  leukocytes  are 
usually  found  in  the  subadjacent  tissues. 

This  type  of  growth  was  classed  by  Gebhard  and  Winter  as  the 
everting  form. 

Growths  which  develop  in  the  glands  of  the  endometrium  present 
a  similar  picture  in  their  earliest  phases.  The  masses  are  composed  of 
cells,  five  or  six  layers  deep,  which  presently  assume  an  atypical  glan- 
dular appearance.  The  cells  may  vary  greatly  in  size,  although  usually 
they  are  much  enlarged.  Their  nuclei  are  also  vesicular  and  stain 
rather  faintly.  Other  types  of  cells  may  be  seen.  Occasionally  there 
are  parallel  rows  of  gland  epithelium,  the  cells  of  which  are  small,  their 
nuclei  large  and  stain  intensely,  resembling  cells  seen  in  chorio- 


282  PELVIC   NEOPLASMS 

epithelioma.  The  gland  epithelium  sometimes  fills  the  entire  cavity 
and  assumes  an  appearance  strongly  suggesting  the  cells  of  the 
squamous  carcinoma.  Mitotic  figures  and  the  tendency  to  invade  is 
seen  in  each  type  of  carcinoma  of  the  uterine  body.  Vacuolization  and 
leukocytic  infiltration  are  present  in  nearly  all  well-developed  cases. 

Either  of  the  two  types  of  growth  may  occur  in  the  carcinoma  which 
develops  in  uterine  polyps  of  the  body  of  the  uterus. 

Method  of  Growth. — The  tumor  early  develops  in  the  plane  of 
least  resistance  and  may  not  invade  deeply  the  underlying  tissues  until 
it  has  been  well  developed  locally.  Early  growths  may  appear  to  be 
limited  to  the  superficial  portions  of  the  endometrium,  yet  cancerous 
areas  can  be  demonstrated  usually  in  the  depths.  A  few  tumors  have 
been  reported  which  were  so  definitely  circumscribed  that  they  ap- 
peared to  have  been  cured  by  curetting.  Just  as  in  cervical  cancer, 
the  division  of  everting  and  inverting  types  is  possible  only  in  the 
early  stages.  There  is  usually  some  infiltration  of  the  underlying 
tissues  by  the  cancer  cells.  Yet  the  tumor  extends  slowly  into  the 
muscular  coat,  usually  in  an  irregular  fashion,  and  does  not  reach  the 
peritoneal  covering  until  late  in  the  disease  and  only  after  the  entire 
uterine  cavity  has  been  replaced  by  cancerous  tissue.  It  is  thought 
that  this  slow  invasion  is  due  to  the  atrophy  of  the  uterine  wall  and 
the  impairment  of  its  lymphatic  drainage  in  consequence  of  the  meno- 
pause. Yet  metastases  may  occur  through  the  lymph  streams  and 
later  through  the  blood  vessels,  although  they  develop  much  more 
slowly  than  in  cancers  of  the  cervix.  Cancers  of  the  fundus  proper 
drain  through  the  lymphatics  of  the  upper  broad  ligament  and  involve 
both  the  inguinal  and  the  pelvic  glands.  Weibel,  in  1913,  presented 
the  results  of  the  study  as  to  the  method  of  metastases  for  cancer  of 
the  corpus  in  Wertheim's  clinic.  He  does  not  share  the  general 
opinion  that  the  lymph  glands  are  seldom  involved  in  carcinoma  of  the 
body  of  the  uterus.  Carcinomatous  glands  were  found  5  times  in  31 
laparotomies  (16  per  cent).  Since  no  particular  attempt  was  made 
to  find  involved  glands  in  some  of  the  earlier  cases,  it  does  not  seem 
improbable  that  these  figures  are  lower  than  the  actual  fact.  It  is  of 
interest  that  the  inguinal  glands  were  only  involved  in  2  cases,  prob- 
ably because  of  the  small  size  of  the  lymphatics  running  along  the 
round  ligaments  in  this  series  of  cases.  He  found  that  the  iliac  and 
lumbar  glands  were  most  commonly  affected  just  as  they  are  in  cer- 
vical carcinoma.  The  glands  were  involved,  although  the  parametrium 
was  perfectly  free  in  several  of  his  cases.  As  a  result  of  his  study, 
he  believes  that  the  chief  channels  for  metastases  in  cancer  of  the 
uterine  body  run:  (i)  along  the  upper  edge  of  the  broad  ligament  to 
the  ovary,  then  along  the  ovarian  vessel  to  the  common  iliacs  and 
the  aorta,  and  thence  to  the  lumbar  glands;  (2)  from  the  middle  of  the 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  283 

corpus  uteri,  transversely  through  the  broad  ligaments  to  the  iliac 
glands  at  the  bifurcation  of  the  common  iliac  artery;  and  (3)  along  the 
walls  of  the  tubes. 

Others  have  found  rather  similar  percentages  of  glandular  involve- 
ment. Baisch  found  the  glands  involved  in  4  of  24  cases,  of  which 
3  showed  involvement  of  the  peritoneum  and  i  of  the  parametrium. 
Meyer,  who  reviewed  Doederlein's  material  from  1902  to  1905,  found 
the  glands  involved  4  times  in  28  cases  which  were  treated  by  abdomi- 
nal operation.  Offergeld  found  the  iliac  and  inguinal  glands  involved 
in  2  of  15  cases,  although  each  presented  a  small  primary  tumor.  Von 
Herff  has  made  similar  observations.  Cullen  found  cancerous  glands 
only  in  a  single  case. 

Nearly  all  agree  that  the  parametria  are  not  involved  until  fairly 
late  in  the  disease.  Kundrat  found  parametric  invasion  in  55  per 
cent  of  his  cases  of  cervical  carcinoma,  yet  in  cancers  of  the  body  it 
was  free  in  nearly  all  save  the  very  late  cases.  Yet  the  parametria 
have  not  been  subjected  to  the  same  careful  study  that  has  been  made 
in  cancers  of  the  cervix.  Baisch  studied  the  parametrium  in  24  can- 
cers of  the  uterine  body  and  found  cancer  but  once.  Pankow  studied 
the  parametrium  in  3  cases,  all  of  which  were  free.  Weibel  studied 
9  cases;  the  parametria  were  free  in  7,  although  the  glands  were  in- 
volved in  2  of  these.  One  of  the  2  cases  in  which  the  parametrium 
contained  carcinoma  had  glandular  involvement  as  well.  These  find- 
ings must  be  taken  into  consideration  in  determining  the  type  of 
operative  treatment. 

Late  in  the  disease,  the  cervix  may  be  invaded  rarely  by  direct 
extension  through  the  internal  os,  or  more  commonly  by  lymphatic 
metastases.  We  have  already  called  attention  to  the  fact  that  the 
lymphatic  plexus  in  the  uterine  body  and  cervix  is  continuous  without 
any  clear  line  of  demarcation.  The  vagina  may  also  be  invaded  by 
metastatic  extension ;  very  rarely,  it  is  involved  by  direct  extension 
through  the  cervical  canal. 

The  ovaries  are  often  affected.  They  may  be  involved  by  direct 
extension  through  the  uterine  wall  to  the  peritoneum  and  along  the 
ovarian  ligament,  or  by  lymphatic  metastases.  The  cancerous  areas 
are  often  small  and  found  only  after  careful  examination.  Occasion- 
ally, the  ovarian  metastases  are  of  considerable  size  and  may  be  larger 
even  than  the  primary  uterine  growth.  The  fallopian  tubes  may  be 
invaded  in  a  similar  manner. 

Metastases  in  remote  organs  are  relatively  rare.  They  are  men- 
tioned in  the  discussion  of  uterine  carcinoma  in  general  (see 
page  203). 

Complications. — Fibroid  tumors  often  coexist  with  cancer  of  the 
endometrium,  in  marked  contrast  to  cancer  of  the  cervix.  Many  have 


284  PELVIC   NEOPLASMS 

urged  that  the  frequent  occurrence  of  fibroids  and  adenocarcinomata 
of  the  uterine  body  suggests  a  common  etiologic  factor.  They  state 
that  the  circulatory  disturbances-  may  well  account  for  the  condition 
which  is  often  found  in  an  endometrium  which  has  diminished  resist- 
ance because  of  the  changes  induced  by  the  fibroid.  Clinically,  the 
frequent  association  of  carcinoma  of  the  uterine  body  with  fibroids 
should  be  borne  in  mind,  since  the  symptoms  of  both  conditions  may 
be  identical  and  the  presence  of  the  carcinoma  may  not  be  suspected. 
The  importance  of  sanguinous  discharges  after  the  menopause  in  a 
fibroid  uterus  cannot  be  emphasized  sufficiently. 

Multiple  Cancers. — The  association  of  two  or  more  malignant 
tumors  is  occasionally  noted.  The  disease  is  often  found  together  with 
cancer  of  the  cervix,  or  cancers  of  the  ovary.  Cancer  of  the  uterine 
body  may  also  occur  with  mammary  cancer  and  primary  carcinoma  of 
the  intestines.  Outerbridge  has  collected  27  cases  of  combined  car- 
cinoma and  sarcoma  of  the  uterus. 

Pyometra. — Pyometra  may  occur  together  with  carcinoma  of  the 
uterine  body.  The  mechanism  of  the  retention  appears  to  vary  in  dif- 
ferent cases;  sometimes  the  discharges  are  retained  by  an  obstruction 
in  the  lower  part  of  the  organ;  in  other  cases,  they  may  be  withheld 
because  the  uterine  wall  is  not  able  to  expel  them,  because  of  atrophy 
associated  with  senility  or,  because  the  wall  has  been  weakened  by 
ulceration  of  its  surfaces. 

Symptoms. — Symptoms  are  usually  present  for  a  considerable 
period  before  the  patient  seeks  medical  advice.  In  spite  of  this  fact,  the 
prognosis  is  favorable  in  comparison  with  that  of  carcinoma  of  the 
cervix  because  the  onset  is  not  so  insidious  and  the  disease  remains 
localized  for  a  fairly  long  time. 

The  symptoms  are  identical  with  those  of  cancer  of  the  cervix.  The 
chief  difference  is  that  leukorrhea  is  not  noted  as  a  rule  as  long  before 
the  appearance  of  blood  as  in  carcinoma  of  the  cervix.  Hemorrhage 
comes  early  and  for  a  long  time  is  apt  to  be  only  spotting.  Sudden 
hemorrhages  are  not  likely  to  come  without  previous  warning.  Pain 
is  a  late  symptom.  The  malodorous  discharge  carries  no  especial  sig- 
nificance, since  it  depends  upon  changes  in  the  vagina. 

Diagnosis. — The  diagnosis  of  cancer  of  the  body  of  the  uterus  is 
usually  made  with  the  microscope,  since  there  are  no  characteristic 
symptoms  or  findings  in  the  earlier  stages  of  the  disease.  It  is  often 
made  in  the  laboratory  upon  growths  which  were  removed  under  the 
impression  that  the  condition  was  only  a  fibroid.  There  are  many  cases 
in  the  literature  which  were  considered  only  retroversions  of  the  uterus 
and  were  treated  by  suspension  after  a  preliminary  curettage.  The 
diagnosis  in  these  cases  was  made  by  the  routine  examination  of  the 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  285 

scrapings    some    days    after    the    operation.      The    need    for    routine 
laboratory  examinations  of  all  scrapings  is  perfectly  obvious. 

Just  as  in  carcinoma  of  the  cervix,  we  should  regard  any  case  as 
cancer  which  presents  leukorrhea  and  bleeding  until  the  tentative  diag- 
nosis has  been  disproved  by  careful  microscopic  study.  All  scrapings 
should  be  studied  macroscopically  before  they  are  sent  to  the  labora- 
tory. White,  opaque  fragments  removed  by  the  curette  usually  indi- 
cate a  cancer  of  the  endometrium,  yet  in  early  localized  cases,  a  small 
focus  may  be  missed  and  the  diagnosis  can  be  made  only  when  many 
blocks  of  the  scrapings  have  been  examined.  The  need  for  a  close 
association  of  laboratory  and  operating  room  cannot  be  advocated  too 
strongly.  Modern  methods  demand  that  all  tissues  removed  in  the 
operating  room  be  studied  immediately  by  frozen  sections  so  that  there 
may  be  no  chance  that  a  diagnosis  of  malignancy  be  made  only  long 
after  the  completion  of  the  operation. 

If  the  curettings  contain  malignant  areas,  the  glandlike  spaces  are 
usually  increased  greatly  in  number  so  that  they  often  lie  close  to 
each  other,  with  only  a  fine  dividing  line  of  spindle  cells  between  them. 
The  acini  frequently  show  marked  irregularities  in  outline,  and  may 
form  an  intricate  network  in  which  it  is  impossible  to  distinguish  the 
individual  gland.  The  characteristic  findings  are  an  increase  in  the 
number  of  layers  and  cells  lining  the  glands,  irregularities  in  the  size 
of  the  individual  cells  and  their  nuceli,  evidences  of  mitosis  and  of 
invasion  of  the  stroma  by  the  proliferating  cell.  Care  must  be  taken  to 
distinguish  from  cancer,  a  normal  gland  which  has  been  cut  obliquely 
in  thick  sections.  The  lining  of  the  gland  in  malignant  adenoma  is 
often  a  single  layer  of  high  cylindrical  cells,  the  nuclei  of  which  are 
irregular  in  shape  and  size,  and  are  placed  at  uneven  levels.  Groups 
of  cells  projecting  in  the  lumen  of  the  gland,  staining  irregularly,  and 
presenting  mitotic  figures  are  suspicious  of  malignancy  and  necessitate 
a  careful  routine  study  of  the  entire  mass  of  scrapings.  When  the 
diagnosis  is  made  by  the  immediate  examination  of  the  scrapings,  the 
case  should  at  once  be  prepared  for  the  removal  of  the  uterus. 

Treatment. — The  treatment  is  operative,  which  nearly  all  agree 
gives  better  results  than  radium.  There  is  not  yet  unanimity  of 
opinion  as  to  the  extent  of  the  removal,  provided  that  panhysterectomy 
with  removal  of  the  adnexa  is  the  minimum.  The  student  should 
realize  that  cancer  of  the  uterine  body  is  a  comparatively  rare  con- 
dition and  that  there  are  few  large  series  of  results  from  which  we  can 
make  deductions. 

There  is  no  doubt  that  vaginal  hysterectomy  has  cured  many  cases 
in  which  the  disease  was  not  far  advanced,  although  all  agree  that  it  is 
not  the  method  of  choice,  since  the  upper  limits  of  the  growth  must 
remain  unknown.  The  results  are  shown  in  the  following  table: 


286 


PELVIC   NEOPLASMS 


Vaginal  hysterectomy 

Number  of 
cases 

Per  cent  of 
five-year  cures 

Glockner,  1887-1897  

6 

66.7 

Krukenberg     

6 

66.7 

Reipen  .... 

8 

7^ 

Frankel  

30 

60 

Chrobak,  1900  .       .        

8 

7< 

Winter,  1  900  

^o 

ca.  3 

Blau   1903           •          

17 

76.4 

Zurhelle   1905             

•i* 

60 

Aulhorn   1909         

o 

Egli,  1918. 

13 

92 

Little  can  be  judged  concerning  the  primary  mortality,  since  the 
great  majority  of  these  cases  were  operated  a  decade  or  more  ago. 
Glockner  had  16  per  cent  primary  mortality;  Frankel,  5.3  per  cent; 
Zurhelle  reports  10  per  cent  in  42  cases  in  the  Bonn  Clinic;  Aulhorn, 
one  death  in  17  vaginal  cases  (6.2  per  cent).  Rouffart,  writing  in  1909, 
stated  that  the  average  mortality  for  the  cases  so  treated  appeared  to 
be  in  the  neighborhood  of  10  per  cent.  It  is  generally  conceded  that, 
in  America,  this  operation  is  usually  done  with  about  5  per  cent  mor- 
tality. Much  better  results  cannot  be  expected  because  of  infected 
vaginae. 

The  results  of  abdominal  panhysterectomies  found  in  the  literature 
do  not  appear  at  first  sight  better  than  those  cited  for  the  vaginal 
operation.  Yet  it  appears  that  the  abdominal  operation  was  usually 
reserved  for  more  extensive  cases  which  could  not  be  approached  as 
safely  by  the  vaginal  route.  Scheib  reports  6  cases  with  75  per  cent 
of  five-year  cures;  Meyer  presents  Doederlein's  results  in  26  cases,  as 
54  per  cent  of  cures.  Wilson  groups  his  cases  which  were  operated  by 
either  the  vaginal  or  abdominal  hysterectomy.  There  were  31  of  these 
which  had  been  studied  for  the  five-year  period.  The  primary  mortal- 
ity was  6.4  per  cent.  Twelve  patients  were  free  from  recurrence  at  the 
end  of  five  years;  operative  cure,  42  per  cent;  absolute  cure,  24  per 
cent. 

All  of  these  cases  must  be  considered  in  the  light  of  the  operability 
of  their  series.  Doderlein,  in  one  year,  operated  14  out  of  a  total  of  17 
cases  (82  per  cent  operability) ;  Zurhelle  reports  the  same  operability 
in  the  Bonn  Clinic;  Krukenberg  operated  63  per  cent  of  57  cases; 
Olshausen  had  67  per  cent;  Pfannenstiel,  61  per  cent;  Kuestner,  55  per 
cent;  Hofmeier,  70  per  cent;  Aulhorn,  100  per  cent. 

Many  careful  students  have  called  attention  to  the  fact  that  cancer 
of  the  uterine  body  has  not  been  studied  nearly  as"  critically  as  cancer 
of  the  uterine  cervix.  They  agree  that  the  glands  are  involved  in  a 
much  greater  percentage  of  cases  than  was  formerly  believed.  They 
call  attention  to  the  fact  that  the  cures  reported  by  many  older 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  287 

observers  were  more  apparent  than  real,  since  they  were  not  always 
considered  in  the  light  of  operability.  Wertheim  and  Reuben  Peterson 
are  convinced  that  their  results  from  the  truly  radical  abdominal  opera- 
tion emphasize  its  advantages.  This  is  well  shown  by  Weibel's  report 
of  Wertheim's  cases. 

Weibel,  in  1913,  states  that  there  were  only  70  cases  of  carcinoma 
of  the  uterine  body  seen  during  fourteen  years  in  Wertheim's  clinic, 
although  more  than  1,500  cases  of  carcinoma  of  the  cervix  presented 
for  treatment  during  the  same  period.  Of  the  70  cases,  97  per  cent 
were  operable,  although  only  67  cases  were  actually  operated.  Vaginal 
extirpations  were  done  36  times  in  the  earlier  years  with  I  death. 
Simple  abdominal  panhysterectomy  was  done  12  times  with  2  deaths. 
Supravaginal  amputation  was  done  3  times  without  death  (condition 
probably  not  recognized  at  operation).  The  radical  abdominal  opera- 
tion was  done  on  16  patients,  4  of  which  died.  The  mortality  for  the 
entire  series  was  10.5  per  cent.  Weibel  states  that  this  was  due  to  the 
large  number  of  elderly  women  in  the  series,  and  their  poor  condition. 
His  series  contained  a  number  of  complications.  In  the  67  operative 
cases,  there  occurred,  in  addition  to  cancer  of  the  corpus,  fibroids  in  19 
cases ;  ovarian  cysts  in  5 ;  ovarian  carcinoma  in  4;  tubal  carcinoma  in  I ; 
ovarian  sarcoma  in  i.  The  uterine  carcinoma  was  found  accidentally  in 
10  cases  after  the  uterus  was  removed  for  i  of  the  above  conditions. 
Recurrence  was  observed  in  19  cases  (30  per  cent)  of  the  60  cases 
which  survived  operation.  The  recurrence  presented  almost  invariably 
within  the  first  year  after  operation.  In  2  cases,  it  was  not  due  to  the 
uterine  carcinoma  but  to  the  malignant  condition  of  the  adnexa  (one 
ovarian  sarcoma  and  one  primary  ovarian  carcinoma).  Forty-three 
cases  were  operated  more  than  five  years  prior  to  the  time  of  his  report. 
Of  these,  5  died  from  the  operation,  16  had  recurrences,  and  the 
remaining  22  are.  alive  and  well  for  more  than  five  years  now,  an 
operative  cure  of  51  per  cent  and  an  absolute  cure  of  50  per  cent.  A 
detailed  review  of  the  series  showed  that  the  best  results  were  obtained 
by  the  radical  abdominal  method  in  which  71  per  cent  of  the  cases  were 
cured  (Winter's  postulates)  in  contrast  to  59  per  cent  of  cures  for 
vaginal  hysterectomies  and  43  per  cent  for  the  abdominal  panhysterec- 
tomies. 

Peterson,  in  1916,  reports  similar  findings.  He  states  that,  in  spite 
of  the  high  primary  mortality  of  the  truly  radical  hysterectomy,  the 
results  are  better  than  those  of  the  ordinary  methods.  Since  1912,  he 
has  had  14  ordinary  hysterectomies  for  cancer  of  the  fundus  which 
showed  worse  primary  and  end  results  than  the  n  cases  which  were 
treated  by  a  truly  radical  operation. 

A  critical  review  of  the  literature  will  convince  nearly  any  student 
that  the  question  of  the  treatment  of  carcinoma  of  the  uterine  body  is 


288  PELVIC   NEOPLASMS 

passing  through  the  same  stages  as  has  been  noted  in  that  of  cancers 
of  the  uterine  cervix. 

Radium. — There  are  no  series  of  size  sufficient  to  permit  the  valua- 
tion of  radium  in  the  treatment  of  this  type  of  growth.  Individual 
experience  and  study  of  the  literature  shows  that  the  tumor  may  be 
cured  by  operation.  The  majority  agree  with  Clark  that  "our  attitude 
toward  cervical  and  fundal  carcinoma  is  diametrically  opposite.  In 
border-line  cases  of  cancer  of  the  cervix  we  invariably  employ  radium.  In 
advanced  cases  of  cancer  of  the  fundus,  we  invariably  perform  hysterec- 
tomy." 


SARCOMA   OF  THE   UTERUS 

Sarcoma  of  the  uterus  is  usually  primary  but  may  develop  in  a 
uterine  fibroma;  or,  secondarily,  from  an  extension  of  sarcoma  in  some 
neighboring  structure,  more  commonly,  in  one  of  the  ovaries.  The  tumor 
may  consist  of  an  everting  fungoid  growth  or. an  inverting  and  infiltrat- 
ing mass,  and  usually  presents  a  uniform  homogeneous  structure  quite 
dissimilar  to  the  gross  picture  of  a  carcinoma. 

Frequency. — Sarcoma  of  the  uterus  is  usually  regarded  as  a  very 
rare  tumor.  Many  authors  state  that  it  is  the  most  uncommon  of  all 
uterine  growths,  yet  it  is  more  than  possible  that  a  careful  microscopic 
examination  made  on  all  fibroids  would  show  that  the  figures  stated 
in  the  literature  are  too  low  to  represent  the  frequency  of  the  disease. 
This  is  strongly  suggested  by  the  work  of  Winter  who  found,  in  1907, 
sarcomatous  changes  in  3.2  per  cent  of  500  fibroid  cases  in  which  only 
the  suspicious  areas  of  the  tumor  were  studied  microscopically  while 
sarcoma  was  found  in  4.3  per  cent  of  253  cases  in  which  careful  micro- 
scopic examinations  were  made  as  a  routine.  It  is  certain,  however, 
that  sarcoma  of  the  uterus  has  rarely  been  reported  in  the  literature. 
The  earlier  literature  did  not  recognize  it,  but  contained  many 
instances  of  recurrent  fibroids,  which  were  considered  as  benign  tumors 
which  followed  operation.  Probably  a  considerable  proportion  of  these 
were  sarcoma.  The  first  sarcoma  of  the  uterus  definitely  recorded  as 
such  and  supported  by  microscopic  examination  was  reported  by 
Lebert,  in  1845.  Yet  this  aroused  very  little  interest  and  the  subject 
did  not  attract  attention  until  after  the  discussion  attending  Mayer's 
case  which  was  reported  to  the  Obstetrical  Society  of  Berlin  in  1860. 
Five  years  later,  Virchow  definitely  established  the  condition  as  a 
pathological  entity  and  gave  the  first  description  of  a  sarcoma  of  the 
endometrium.  In  1867,  Veit  collected  3  cases  of  uterine  sarcoma  and, 
in  1871,  Senn  and  Keegar  reviewed  the  subject  from  a  study  of  9 
recorded  cases.  Gurlt  found  only  2  sarcoma  in  2,649  uterine  tumors 
and  remarked  the  frequency  of  carcinoma  of  the  uterus  to  sarcoma  as  I 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  289 

to  785.  Roger  Williams,  in  his  review,  found  only  8  sarcoma  in  4,115 
uterine  tumors.  In  1894,  Whitridge  Williams  was  able  to  collect  but 
144  cases  from  the  medical  literature.  Since  then,  a  total  of  about  500 
cases  has  been  reported. 

The  relative  frequency  of  cancer  and  sarcoma  of  the  uterus  is  vari- 
ously given.  Geisler,  basing  his  conclusions  on  his  Breslau  material, 
states  that  the  relative  frequency  of  sarcoma  to  carcinoma  is  i  to  50. 
Veit,  reviewing  his  work  in  Halle  for  seventeen  years,  found  40  sar- 
comata in  contrast  to  1,493  carcinomata,  a  frequency  of  I  to  37.  Kru- 
kenberg  reports  that  the  frequency  in  the  Frauenklinik  was  I  to  47.5. 
Von  Franque  observed  the  relative  proportion  as  I  to  20,  and  considers 
sarcoma  as  equal  in  frequency  to  carcinoma  of  the  body  of  the  uterus. 
Poschmann,  in  Halle,  found  that  sarcomata  were  observed  in  but  16 
of  403  uterine  tumors,  the  other  387  being  carcinomata.  Of  the  16  sar- 
comata, 1 1  were  fundal  and  5  were  in  the  cervix,  while  of  the  387  car- 
cinomata, 10  were  of  the  fundus  and  377  were  in  the  cervix.  The  pro- 
portions stated  above  may  be  too  conservative,  because  there  are  many 
difficulties  in  diagnosing  a  uterine  sarcoma.  Not  infrequently,  the 
tumors  may  be  confounded  with  carcinoma,  since  there  are  types  of 
sarcoma,  occurring  especially  in  the  cervix,  which  present  an  alveolar 
arrangement  which  may  be  readily  mistaken  for  a  tumor  arising  from 
epithelial  elements;  the  clinical  symptoms  may  be  identical. 

Etiology. — Nothing  is  known  concerning  the  etiology  of  sarcoma. 
Predisposing  causes,  such  as  heredity,  previous  inflammation  of  the 
uterus,  obstetrical  or  operative  trauma,  previous  pregnancies,  appar- 
ently have  no  contributing  relationship.  Many  theories  have  been 
advanced  to  explain  the  pathogenesis,  but  they  may  be  grouped  under 
the  following  three  heads:  (i)  sarcomata  developed  by  proliferation 
of  cells  of  the  vessel  walls;  (2)  sarcomata  developed  by  proliferation 
of  the  cells  of  the  intermuscular  fibrous  tissue;  or  (3)  sarcomata  devel- 
oped by  the  transformation  of  smooth  muscle  fibers.  It  would  appear 
possible  that  each  of  these  theories  may  explain  the  origin  of  certain 
cases,  yet  it  is  also  evident  that  all  cases  cannot  be  explained  by  one 
theory.  Virchow's  theory  that  the  tumor  arises  by  multiplication  of 
the  cells  of  the  interstitial  connective  tissue  has  been  supported  by  the 
facts  observed  in  a  number  of  cases.  Kleinschmidt  and  Pilliet  and 
others  have  adduced  evidence  in  favor  of  the  vascular  origin.  Williams, 
Piquand,  von  Kahlden,  Ribbert,  and  others,  offer  evidence  in  favor  of 
the  transformation  of  muscle  fibers  into  malignant  cells.  Certain 
authors — as,  for  example,  Ribbert —  limit  the  term  "sarcoma"  to  the 
tumors  which  arise  by  the  proliferation  of  ordinary  connective  tissue, 
and  describe  the  growths  which  develop  by  the  proliferation  of  muscle 
fibers  as  a  distinct  variety  of  tumor  which  they  designate  "leiomyoma 
malin."  Ribbert  believes  that  the  latter  tumor  is  not  a  degeneration  of 
muscle  cells,  but  the  result  of  a  proliferation  of  muscle  fibers.  In  a 


2  go  PELVIC   NEOPLASMS 

case  described  by  Pavoit  and  Berard,  both  the  primary  tumor  and  the 
metastatic  nodules  were  composed  of  proliferating  muscle. 

Age. — The  disease  may  develop  in  the  uterus  at  any  time  from 
early  infancy  to  old  age;  yet,  as  in  carcinoma  of  the  uterus,  it  occurs 
more  commonly  about  the  time  of  the  menopause.  Gusserow  collected 
73  cases,  4  of  which  were  under  twenty-nine  years;  15,  between  thirty 
and  forty;  28,  between  forty  and  fifty;  18,  between  fifty  and  sixty;  and 
3,  in  women  over  sixty.  Meyer  found  that  85  cases  occurred  between 
forty-five  and  fifty  years  in  his  compilation  of  more  than  460  cases. 
There  is  on  record  a  case  in  which  sarcoma  of  the  uterus  was  observed 
in  a  woman  more  than  seventy.  Grapelike  sarcoma  of  the  cervix  is 
slightly  more  frequent  in  infancy.  Hollander  reported  a  case  in  an 
infant  of  seven  months. 

Location  of  the  Tumor. — The  sarcoma  may  occur  in  the  uterine 
body  or  in  the  cervix.  The  former  position  is  more  common.  Piquand, 
in  a  study  of  393  recorded  cases,  found  that  325  were  in  the  body  and  68 
were  in  the  cervix.  Other  writers  state  that  sarcoma  of  the  uterine 
body  are  even  more  frequent  than  shown  by  these  figures  and  that 
they  occur  at  least  five  times  as  commonly  as  sarcoma  of  the  cervix. 

Classification. — Uterine  sarcoma  may  be  primary  or  secondary  to 
other  growths.  They  may  also  be  classified  according  as  they  develop 
in  the  cervix  or  the  body  of  the  uterus.  Each  of  these  general  group- 
ings may  be  subdivided  according  as  they  develop  from  the  mucosa  or 
the  parenchyma.  The  tumors  may  be  diffuse  or  circumscribed.  Sar- 
coma of  the  cervix  may  be  further  divided  according  to  their  morphol- 
ogy into  two  groups:  (i)  an  indefinite  group  comprising  the  ordinary 
varieties  of  sarcoma;  and  (2)  the  mixed  forms,  which  may  contain  vari- 
ous tissues,  such  as  bone  cartilage,  etc. 

(i)  SARCOMA  OF  THE  UTERINE  BODY  ARISING  FROM  THE  MUCOSA. 
— This  may  occur  in  one  of  two  forms,  diffuse  or  circumscribed.  In 
all  probability,  the  type  arising  from  the  endometrium  is  much  less 
frequent  than  that  developing  from  the  uterine  wall,  although  it  is  often 
impossible  to  determine  the  exact  point  of  origin  of  the  tumor,  since 
the  growths  have  usually  overrun  all  landmarks  when  the  case  first 
presents  for  treatment. 

(a)  Diffuse  Type. — The  diffuse  type  of  growth  is  far  more  common 
than  the  circumscribed.  It  usually  originates  in  the  fundus  and  spreads 
so  as  to  involve  the  whole  mucosa  of  the  uterine  body.  It  is  usually 
limited  by  the  internal  os,  but  occasionally  overcomes  this  barrier  and 
spreads  into  the  cervix.  These  cases  are  usually  found  in  the  adults 
and  are  rare  in  early  life.  As  the  tumor  grows,  the  uterus  becomes 
uniformly  enlarged  and  may  resemble  a  gravid  organ.  On  section,  the 
endometrium  is  thickened,  and  presents  a  shaggy  polypoid  picture. 
The  sarcomatous  structures  are  homogeneous,  cheesy,  and  pale  yellow 
in  color,  although  areas  of  hemorrhage  and  necrosis  are  often  noted. 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  291 

The  line  of  demarcation  between  the  mucosa  and  the  underlying  myo- 
metrium  is  usually  sharp,  although  it  is  less  distinct  in  the  rapidly 
growing  tumors  which  tend  to  spread  through  all  the  tissues.  Even 
though  gross  invasion  of  the  muscle  cannot  be  seen  with  the  naked 
eye,  it  can  usually  be  made  out  with  a  microscope.  The  tumor  may 
extend  along  the  fallopian  tubes  or  directly  through  the  uterine  wall. 

(b)  Circumscribed  Type. — This  begins  as  a  nodule  in  the  deeper  part 
of  the  endometrium  and  may  extend  inward  into  the  uterine  cavity  or 
outward  into  the  uterine  wall.  In  the  former  case,  it  develops  in  the 
cavity  of  the  uterus  and  presents  as  a  fibroid  polyp.  This  tumor  may 
finally  dilate  the  cervix  and  reach  into  the  vagina  when  portions  may 
slough  off  and  be  expelled  or  the  whole  mass  may  become  strangulated 
and  secondarily  infected.  When  it  grows  outward,  it  may  perforate 
the  uterine  wall  and  invade  the  peritoneum  of  Douglas's  pouch  or  may 
grow  into  the  cornua  of  the  tubes.  Histologically,  these  tumors  may 
present  any  variety  of  a  sarcomatous  cell,  although  the  round-celled 
type  seems  more  common.  Blood  vessels  are  numerous  and  enlarged 
sinuses  are  frequently  found.  The  sarcoma  cells  often  present  a  dis- 
tinct perivascular  arrangement.  The  supporting  stroma  varies  greatly 
in  amount  but  usually  is  scanty.  When  the  uterine  wall  has  been 
invaded,  necrosis  commonly  ensues.  Secondary  infection  and  hemor- 
rhage is  common.  Pigment  is  often  found  in  the  cells  of  cases  which 
are  complicated  by  hematometra  or  pyometra.  Melanotic  uterine  sar- 
comata have  been  reported.  The  pelvic  lymph  glands  which  are 
involved  may  present  cystic  degeneration. 

(2)  SARCOMA  OF  THE  UTERINE  MUSCLE. — This  tumor  may  arise  as  a 
primary  growth,  or  may  develop  in  a  preexisting  fibroid.  It  may  likewise 
appear  in  one  of  two  forms:  (a)  diffuse;  or  (b)  circumscribed. 

(a)  Primary  Diffuse  Type. — This  type  is  very  rare  and  is  not  often 
considered  in  pathological  descriptions.     When  the  uterus  is  involved 
by    this    growth,    usually    it    becomes    soft,    smooth    in    outline,    and 
resembles  a  pregnant  organ.     The  cavity  is  usually  enlarged  and  the 
endometrium  is  thickened.     The  tumor  may  invade  the  mucosa  and 
project  into  the  cavity  of  the  uterus  when  it  is  only  with  the  greatest 
difficulty  distinguished  from  a  primary  growth  of  the  endometrium. 

.  Histologically,  the  growth  is  composed  of  round  or  spindle-shaped  cells 
found  diffused  throughout  the  entire  thickness  of  the  uterine  wall, 
lying  between  what  is  left  of  the  muscle  fibers.  The  tumor  cells  are 
believed  to  originate  from  the  intermuscular  or  perivascular  connective 
tissue.  It  is  quite  possible  that  many  of  this  class  of  tumors  are  better 
described  as  peritheliomata. 

(b)  Primary  Circumscribed  Type. — This  type  consists  only  of  sar- 
comatous nodules  which  arise  de  novo  in  the  uterine  wall.     It  is  highly 
probable  that  many  cases  are  confused  with  sarcoma  arising  in  a  fibroid 
which  is  more  common.     It  is  agreed,  however,  that  these  two  forms 


2Q2 


PELVIC  NEOPLASMS 


account  for  the  great  majority  of  uterine  sarcoma.  In  the  earliest 
stages,  the  growth  is  definitely  circumscribed,  although  it  is  rarely 
encapsulated.  Microscopically,  the  very  early  stages  may  be  indis- 
tinguishable from  early  fibroids.  Later,  it  spreads  and  invades  the 
uterine  wall  and  becomes  either  subperitoneal  or  submucous.  The 
former  type  may  break  through  into  the  pouch  of  Douglas.  The  latter 
projects  into  the  uterine  cavity  and  tends  to  become  polypoid.  It 
may  project  through  the  cervix  and  resemble  the  grapelike  sarcoma 
of  the  cervix  (Pick).  Obviously,  these  cases  may  be  confused  with 
growths  which  originate  in  the  endometrium. 

The  entire  group  of  polypoid  cases  may  be  confused  with  "recurrent 
fibroids."  Under  the  latter  term  are  designated  tumors  which  suc- 
cessively cast  off  pedunculated  masses  from  the  uterine  cavity,  which 
are  considered  fibroids  until  their  true  nature  has  been  disclosed  by 
histologic  study  after  removal  of  the  uterus.  Thus  Holland  records  a 
case  in  which  three  fibrous  polypi  were,  within  a  few  months,  thrown 
off  spontaneously  from  the  uterine  cavity  or  were  removed  by  the 
snare.  There  were  no  histologic  examinations.  When  the  uterus  was 
subsequently  removed,  it  was  found  to  contain  a  large  sarcoma  which, 
originally  circumscribed,  was  rapidly  becoming  diffuse.  Croom  records 
a  similar  case  which,  in  his  early  experience,  returned  to  his  wards  in 
Edinburgh  six  times  in  a  little  more  than  two  years.  On  each  occasion, 
he  removed,  by  a  snare,  huge  masses  of  apparently  edematous  fibroids, 
some  of  which  were  as  large  as  a  fetal  head.  The  pathologists-  con- 
sidered them  fibroids.  When  the  uterus  was  finally  removed,  it  was 
found  to  be  sarcomatous.  Such  cases  may,  however,  represent  the 
large  class  of  cases  in  which  the  fibroids  secondarily  become  sarcoma. 

The  sarcomata  which  remain  localized  in  the  uterine  wall  seldom 
attain  any  great  size.  On  the  contrary,  the  submucous  and  subserous 
forms  may  attain  enormous  dimensions.  Perrin  described  a  case 
weighing  nine  kilograms  while  Piquand's  case  weighed  twenty  kilo- 
grams. 

The.  consistency  of  the  tumors  varies,  since  they  frequently  con- 
tain cysts.  They  are  never  as  hard  as  fibroids.  On  section,  they  pre- 
sent a  homogeneous,  cheesy  or  brainlike  appearance  and  are  yellowish- 
pink  in  color.  They  frequently  show  areas  of  old  hemorrhages  result- 
ing from  rupture  of  the  thin-walled  capillaries.  Cysts  are  common  and 
may  be  as  large  as  an  orange.  The  smaller  ones  result  from  edema, 
while  the  larger  ones  result  from  lymphatic  dilatation  or  from  necrosis 
of  the  sarcomatous  tissue.  There  are  also  telangiectatic  varieties, 
which  contain  many  large  sinuses  composed  of  dilated  blood  vessels. 
Histologically,  the  tumors  are  found  to  contain  both  round  and  spindle 
cells,  although  pure  forms  are  recognized.  The  presence  of  giant  cells 
should  excite  the  suspicion  that  the  tumor  is  a  rhabdomyosarcoma. 

(3)   SARCOMA  ARISING  FROM  A  PREEXISTING  FIBROID. — This  type  usu- 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  293 

ally  arises  in  the  center  of  the  fibroid  and  presents  an  area  which  may  be 
clearly  differentiated  from  the  surrounding  fibroid  tissue.  Occasionally, 
it  is  found  in  the  periphery  of  the  tumor.  While  fibroids  rarely  occur 
singly,  the  malignant  change  is  usually  found  in  only  one  of  the  group. 
The  condition  is  readily  recognized  in  developed  cases,  although  the* 
early  stages  may  not  show  macroscopic  change.  The  tumor  may  be 
somewhat  circumscribed  or  occur  as  a  diffuse  infiltration  throughout 
the  fibroid  tumor.  With  the  advance  of  the  growth,  metastases  may 
appear  in  the  muscular  wall  of  the  uterus  outside  of  the  fibroid  proper. 
On  cut  section,  the  sarcomatous  area  presents  the  usual  homogeneous, 
cheesy,  yellowish  appearance  with  frequent  hemorrhagic  areas  and 
cystic  spaces. 

The  histogenesis  of  this  type  of  sarcoma  has  been  the  subject  of  much 
discussion  and  various  theories  have  been  advanced  to  explain  its 
origin.  All  agree  that  sarcoma  may  develop  from  the  connective  tissue 
of  the  fibroid.  There  is  a  difference  of  opinion  as  to  whether  it  may 
also  arise  from  muscle  cells.  Von  Kahlden  was  the  first  to  claim  to 
have  observed  the  direct  transition  of  the  myomatous  cells  into  sar- 
coma cells.  While  all  have  not  accepted  his  case  as  proved,  there  is  no 
doubt  concerning  Williams'  case  and  that  of  a  long  list  of  others.  Kelly 
and  Cullen  observed  the  transition  in  13  of  17  cases  and  Meyer  states 
that  the  muscle  cell  sarcoma  is  the  most  common  form  of  uterine  sar- 
coma. The  majority  of  the  men  who  are  interested  in  this  phase  of  the 
subject  regard  the  transition  from  muscle  to  sarcoma  cells  as  an 
instance  of  metaplasia  from  a  muscle  to  a  connective  tissue  type  of 
cell.  Meyer,  on  the  other  hand,  does  not  agree,  and  believes  that  the 
tumor  is  but  an  instance  of  a  destructive,  exuberant  growth  of  im- 
mature muscle  cells,  the  degenerate  forms  of  which  are  indistinguish- 
able from  those  of  connective  tissue  cells.  The  transition  usually 
appears  as  a  gradual  enlargement  of  the  ordinary  fibromyomatous 
muscle  cell  and  of  its  nucleus,  with  an  increase  in  the  nuclear  chromatin 
until  there  presents  the  large  spindle-shaped  sarcoma  cell.  The  change 
can  be  seen  usually  only  in  the  periphery  of  the  fibroid  nodule.- 

The  differentiation  between  rapidly  growing  fibroids  and  a  definite 
malignant  neoplasm  may  not  be  easy.  What  one  observer  would 
regard  as  benign  may  be  classed  as  malignant  by  another  equally  com- 
petent pathologist.  There  is,  however,  some  prospect  of  attaining 
more  definite  knowledge  as  a  result  of  Mallory's  stains,  by  which 
special  method  he  has  been  able  to  demonstrate  the  different  features 
of  the  myoglia  and  the  fibroglia  fibroids.  Naturally,  the  confusion  in 
the  differentiation  obtains  only  in  the  tumors  which  have  not  given 
metastases. 

SARCOMA  OF  THE  CERVIX. — (a)  ARISING  FROM  THE  MUCOSA. — This 
may  occur  as:  (i)  diffuse;  or  (2)  circumscribed  growths.  Of  special 
interest  is  that  form  of  circumscribed  cervical  growth  which  has  been 


294  PELVIC  NEOPLASMS 

designated  as  grapelike  sarcoma  of  the  cervix  or  sarcoma  botryoids. 
This  tumor  arises  from  the  superficial  layers,  either  of  the  mucosa  of 
the  cervical  canal  or  from  the  portio,  and  comes  to  assume  an  appear- 
ance not  unlike  that  of  a  bunch  of  grapes  or  of  a  hydatidiform  mole. 
It  usually  grows  very  rapidly  and  may  completely  block  the  canal,  pro- 
trude from  the  cervical  os,  and  even  fill  the  vagina.  It  may  appear  at 
any  age.  The  tumor  begins  as  small  polypoid  outgrowths  which  can- 
not be  distinguished  from  a  simple  mucous  polyp  by  the  naked  eye.  In 
the  beginning,  the  growth  develops  slowly  but,  after  a  variable  period 
of  quiescence,  it  rapidly  enlarges.  The  tumor  is  composed  of  two  dis- 
tinct portions,  a  superficial  part  containing  the  translucent  vesicles,  and 
a  supporting  stem  of  fibrous  tissue  which  is  continuous  with  the  sub- 
mucosa  of  the  cervix.  As  the  disease  progresses,  the  vaginal  vault 
is  invaded  and  finally  the  mucosa  is  penetrated  and  the  neoplasm  infil- 
trates the  vesicovaginal  and  rectovaginal  septum,  and  ultimately  the 
parametric  and  regional  lymph  glands  become  involved.  Distant 
metastases  have  been  described,  although  rarely.  On  microscopic 
examination,  the  growth  is  found  to  correspond  to  that  of  myosarcoma 
of  the  vagina.  The  free  surface  of  the  vegetations  are  covered  in  part 
by  typical  epithelium  of  the  cervical  canal,  and  the  remainder  by  cells 
derived  from  the  stratified  epithelium  of  the  portio.  There  is  usually 
considerable  superficial  erosion.  Striated  muscle  and  hyaline  cartilage 
have  been  found  in  the  deeper  portion  of  the  neoplasm.  Webber  first 
reported  the  general  type  in  1867,  although  the  subject  did  not  assume 
interest  until  following  Spiegelberg's  paper  in  1879.  The  term  "grape- 
like"  was  suggested  by  Pfannenstiel  in  1892,  although  it  was  not  then 
recognized  that  the  cystic  spaces  in  the  tumor  were  due  to  edema  from 
the  rapidly  growing  sarcoma. 

(b)  ARISING  FROM  THE  FIBROMUSCULAR  COAT  OF  THE  CERVIX. — This 
form  is  very  rare.  It  may  arise  as  a  primary  growth  or  as  a  malignant 
degeneration  of  a  preexisting  fibroid.  The  latter  are  at  first  circum- 
scribed but  may  break  through  and  present  upon  the  surface  as  a  more 
diffuse  growth.  In  the  diffuse  form,  the  mucosa  may  be  entirely 
involved  but  usually  the  vaginal  portion  of  the  cervix  shows  the  most 
extensive  invasion.  The  cervix  appears  greatly  hypertrophied  and 
infiltrated  and  its  surface  may  be  covered  with  irregular  vegetations 
which  resemble  very  closely  carcinoma.  The  circumscribed  type  may 
be  either  sessile  or  pedunculated,  the  former  appearing  as  an  irregular 
vegetating  growth  which  arises  from  either  the  anterior  or  posterior 
lip.  Piquand  states  that  this  form  may  be  differentiated  from  a  car- 
cinoma by  its  greater  softness  and  size.  There  is  also  less  tendency  to 
necrosis. 

The  pedunculated  sarcoma  or  sarcomatous  polyp  is  the  most  com- 
mon form  of  cervical  sarcoma.  It  may  be  attached  to  the  cervical 
canal  by  a  pedicle  of  various  lengths  and  thicknesses,  or  to  the  vaginal 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  295 

portion  of  the  cervix  when  it  appears  as  an  irregularly  rounded  tumor 
which  is  sometimes  lobulated.  It  is  soft  in  consistency  and  pinkish 
gray  in  color.  Occasionally  it  is  fairly  dense,  when  it  is  composed  of 
cellular  tissue  without  evident  edema.  The  early  growth  has  a  smooth 
surface,  covered  by  normal  epithelium  which  later  becomes  eroded. 
Extensive  degenerations  are  not  uncommon. 

Round-,  spindle-,  and"  mixed-cell  sarcomata  occur  with  about  equal 
frequency.  Giant  cell  growths  are  also  described.  There  are  records 
of  several  melanotic  sarcomata,  one  of  which,  quoted  by  Williams,  had 
given  pigmented  metastases  to  the  brain  and  other  organs.  Girandel 
described  a  case  in  which  myomatous  nodules  were  found  in  the  liver, 
kidney,  intestines  and  uterus,  and  which  contained  melanotic  cells. 
Hyaline  degeneration  is  frequently  found,  particularly  around  blood 
vessels  and  in  the  older  portions  of  the  tumor. 

Special  Forms  and  Mixed  Types. — A  large  number  of  sarcomata 
must  be  placed  in  this  group.  Their  interest  is  chiefly  from  the  patho- 
logic side.  We  have  already  mentioned  melanosarcomata.  Many  would 
place  myxosarcomata  under  this  classification,  although  Piquand  be- 
lieves that  the  majority  of  these  are  really  edematous  tumors.  Von 
Franque,  and  a  few  others,  however,  have  recorded  true  myxomatous 
tumors.  Lymphosarcomata  have  been  described  by  Gow,  Schlagen- 
haufer,  and  others.  They  were  characterized  by  a  rich  lymphatic 
plexus  with  numerous  dilated  spaces  which  accounted  for  the  softness 
of  the  tumor. 

A  lipomyosarcoma  has  been  described  by  Sitzenfrey. 
True  angiosarcomata  have  been  reported  in  which  the  tumors  were 
partly  composed  of  sarcoma  cells  and  partly  of  new-formed  blood 
vessels.  Often,  however,  we  find  a  perivascular  arrangement  made  by 
the  sarcoma  cells,  while  the  blood  vessels  have  not  developed  to  an 
extent  which  warrants  the  term  "angioma."  Some,  of  .the  peritheli- 
omata  are  described  as  alveolar  sarcomata. 

A  number  of  cases  have  been  described  in  which  cartilage  was 
present  in  the  sarcomatous  mass.  This  type  is  termed  chondrosarcoma. 
Some  believe  that  the  cartilaginous  areas  are  due  to  a  metaplasia  of  the 
connective  tissue  cells;  the  greater  number,  however,  regard  the 
growth  as  a  mixed  mesodermal  tumor.  Cartilaginous  elements  have 
been  observed  in  the  grapelike  tumors  of  the  cervix  by  Pfannenstiel, 
Pernice,  and  others.  An  adenofibromyxochondrosarcoma  of  the  cervix 
has  been  described  by  Puech  and  Massabuau. 

RhabdoDiyosarcomata  have  been  reported  by  a  number  of  authors. 
Bell  has  collected  17  such  cases.  The  majority  of  these  mixed  types 
occur  in  the  cervix.  Herb  states  that  only  8  have  been  found  in  the 
body  of  the  uterus,  for  the  most  part  in  the  cornua  or  on  the  posterior 
wall. 

There  is  a  confusing-  group  of  tumors  which  are  usually  termed  car- 


296  PELVIC   NEOPLASMS 

cinoma  sarcomatodes,  which  appear  to  present  both  the  characteristics 
of  carcinoma  and  sarcoma  in  a  single  specimen.  Formerly  they  were 
regarded  as  a  separate  type,  but,  in  recent  times,  the  majority  of 
students  consider  that  they  are  properly  sarcoma.  Some  have  been 
reported  as  endothelioma,  presenting  an  alveolar  arrangement  which 
is  most  difficult  to  distinguish  from  carcinoma  but  have  been  excluded 
in  the  critical  studies  by  the  students  of  endothelioma.  There  are, 
however,  a  number  of  cases  which  have  been  adduced  by  competent 
men  as  examples  of  double  malignant  tumors.  Fisher-Defoy  and 
Lubarsch,  in  1905,  admitted  that  there  were  13  cases  entitled  to  this 
classification.  Taylor  and  Teacher,  in  1909,  recorded  6  others,  4  of 
which  occurred  in  the  body  of  the  uterus.  Johnstone  states  that  this 
group  is  of  particular  interest  in  the  light  of  Russell's  demonstration 
that  sarcoma  may  develop  during  the  experimental  propagation  of  an 
adenocarcinoma  of  the  mouse. 

Method  of  Extension. — Uterine  sarcomata  are  spread  by  direct 
extension  and  by  metastases.  In  the  earlier  stages,  the  growth  may  be 
definitely  circumscribed,  but,  in  its  development,  the  tumor  spreads 
outward  toward  the  peritoneal  cavity  or  inward  toward  the  uterine 
cavity.  Cervical  sarcomata  spread  toward  the  vagina.  Uterine  sar- 
comata often  remain  dormant  .or  grow  slowly  for.  a  long  period  and 
then  develop  very  rapidly.  This  feature  of  growth  is  seen  especially  in 
the  cases  in  which  sarcoma  originates  in  the  fibromyomatous  nodules 
and  may  be  accounted  for  by  the  resistance  of  the  capsule. 

The  later  stages  are  usually  accompanied  by  metastases.  Masses 
may  be  found  in  the  posterior  cul-de-sac,  or  the  parametrium,  which 
may  be  so  filled  with  malignant  tissue  as  to  exert  pressure  on  the 
ureters  and  cause  hydronephrosis.  This  complication,  however,  is  not 
as  frequent  as  in  carcinoma.  This  type  of  invasion  has  been  adduced 
as  an  example  of  metastases,  yet  is  probably  due  to  direct  extension. 
Metastatic  deposits  may  be  found  in  remote  organs,  as  the  lungs,  liver, 
and  retroperitoneal  glands.  The  cells  are  carried  by  the  blood  channels, 
and  Katz  has  found  sarcomatous  emboli  in  the  pulmonary  veins.  Sar- 
comatous  thrombi  are  often  found  in  pelvic  veins.  The  extension  may 
also  occur  through  the  lymphatics,  as  is  proved  by  cases  presenting 
discontinuous  involvement  of  the  parametrium.  Gessner  believes  that 
metastases  are  more  frequent  than  is  usually  considered,  and  can  be 
proved  only  by  careful  post-mortem  examination.  The  frequency  of 
recurrence  after  operation  certainly  supports  this  view. 

Complications. — Pyometra  and  hematometra  may  occur  when  the 
drainage  of  the  uterus  is  blocked  by  the  tumor.  Occasionally,  the 
uterine  cavity  may  be  distended  with  a  large  amount  of  fluid.  Terrillon 
reports  a  case  in  which  the  uterus  contained  seven  liters  of  fluid  and 
refers  to  a  case  of  Pean  in  which  there  were  fifteen  liters.  There  are  a 
number  of  cases  of  inversion  of  the  uterus  cited  in  the  literature.  These 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  297 

have  occurred  almost  without  exception  when  the  sarcomatous  mass 
was  of  considerable  size.  The  peritoneal  cavity  has  been  opened  in 
several  cases  when  the  physician  mistook  the  inverted  fundus  for  the 
pedicle  of  the  tumor.  There  are  at  least  2.  cases  in  which  the  inversion 
occurred  in  nulliparous  women  (Simpson,  Spiegelberg).  Constitu- 
tional symptoms  may  be  caused  by  secondary  changes  in  the  tumor, 
such  as  necrosis  and  hemorrhage. 

Symptoms. — The  classical  symptoms  are  hemorrhage,  pain,  dis- 
charge, and  pressure.  The  extent  and  intensity  of  these  vary  greatly, 
depending  for  the  most  part  upon  the  size  and  situation  of  the  tumor. 
Very  rarely,  cachexia  is  the  first  symptom,  noted  almost  without  ex- 
ception when  the  growth  has  developed  in  the  vaginal  fornix  and  has 
grown  in  the  plane  of  least  resistance  down  into  the  vaginal  cavity. 

The  hemorrhage  usually  first  appears  as  a  prolonged  menstrual 
period.  Jt  may  not  occur,  however,  until  after  the  menopause. 
Irregular  hemorrhage  may  occur  after  over  exertion  or  trauma.  Since 
the  growth  does  not  ulcerate  as  a  rule  as  early  as  carcinoma,  the 
hemorrhage  usually  comes  from  hyperemia  of  the  mucosa. 

Pain  is  a  common  symptom.  Its  amount  varies,  depending  upon 
the  location  of  the  tumor.  It  may  be  very  intense  when  the  uterine 
cavity  is  suddenly  distended  as  by  polypoid  growths  or  hemorrhage. 
There  is  much  pain  in  the  late  stages  of  the  disease  as  a  rule.  There 
are  a  few  cases  in  which  tumors  of  considerable  size  were  not  accom- 
panied by  pain.  Clay,  A.  R.  Simpson,  Howard  Taylor,  and  others 
have  reported  examples.  There  may  be  very  little  pain  when  the 
sarcoma  has  developed  in  fibromyomatous  nodules  and  has  not  broken 
through  the  capsule. 

Discharge  is  usually  present  in  the  intervals  between  the  hemor- 
rhages. It  resembles  ricewater  in  appearance  and  is  not  often  as 
offensive  as  that  in  carcinoma.  When  the  disease  has  progressed  to  a 
considerable  extent,  the  discharge  may  be  very  fetid.  The  older 
writers  call  attention  to  the  presence  in  the  discharge  of  grayish  white 
shreds,  resembling  particles  of  brain  matter.  These  are  tumor  masses 
which  have  broken  away.  They  are  diagnostic  when  they  occur,  but 
since  they  occur  late  in  the  disease,  the  diagnosis  should  already  have 
been  made. 

The  symptoms  vary  somewhat,  depending  on  the  location  of  the 
tumor. 

Sarcoma  of  the  Uterine  Wall. — The  symptoms  of  this  type  of 
growth  may  be  that  of  an  ordinary  fibroid  unless  it  develops  after 
the  menopause.  The  hemorrhage  usually  begins  as  a  menorrhagia. 
The  anemia,  however,  is  more  marked  than  that  of  fibroids  in  general. 
The  development  of  cachexia  may  first  reveal  the  true  nature  of  the 
tumor.  In  the  interval  between  the  hemorrhages,  there  is  present,  in 
the  later  stages  of  the  disease,  the  watery  discharge  which  has  just 


298  PELVIC  NEOPLASMS 

been  commented  upon.  If  the  tumor  grows  toward  the  peritoneum, 
there  may  be  only  slight  menorrhagia  as  an  early  symptom.  There  is 
usually  not  much  pain  with  interstitial  tumors.  It  is  more  common  with 
the  subperitoneal  growths  which  are  complicated  by  peritonitic  reac- 
tions. The  pain  may  be  intense  as  a  result  of  the  spasmodic  contrac- 
tions of  the  uterus  in  its  efforts  to  expel  submucous  tumors. 

Sarcoma  of  the  Endometrium. — The  symptoms  of  this  group  are 
similar  to  those  of  uterine  cancer,  namely,  hemorrhage,  a  watery  dis- 
charge which  finally  becomes  purulent,  and  pain.  The  bleeding  soon 
becomes  continuous.  Pain  is  usually  a  late  symptom.  It  is  severe, 
when  the  growth  has  become  pedunculated  and  causes  spasmodic  con- 
tractions of  the  uterus,  or  when  the  tumor  has  penetrated  the  para- 
metrium.  It  is  a  common  sequence  of  secondary  infection. 

Sarcoma  of  the  Cervix. — Many  of  these  cases  give  no  symptoms 
until  very  late  in  the  disease,  especially  if  there  is  no  necrosis  of  the 
tumor.  As  a  rule,  however,  the  hemorrhage  is  profuse,  as  is  the  watery 
discharge,  and  anemia  develops  at  a  fairly  early  period.  Pressure 
symptoms  are  nearly  invariable  when  the  tumor  is  large  and  fills  the 
vagina,  since  the  pelvic  organs  are  usually  infiltrated  by  sarcomatous 
cells  and  secondary  infiltration. 

Diagnosis. — Correct  diagnosis  is  fairly  uncommon  until  late  in  the 
disease,  since  the  symptoms  at  first  resemble  those  of  an  ordinary 
fibroid.  Rapid  enlargement  of  a  uterus  which  is  known  to  contain  a 
fibroid  should  excite  suspicion,  although  this  feature  often  follows 
degenerations  in  a  fibroid  tumor.  Sarcoma  should  be  suspected  when 
the  tumor  increases  after  the  menopause  or  when  hemorrhage  recurs 
after  the  climacteric  has  been  definitely  established.  The  presence  of 
ascites  should  also  suggest  the  diagnosis,  although  this  symptom  may 
be  seen  in  connection  with  nonmalignant  tumors. 

If  the  tumor  projects  through  the  cervix,  the  mass  will  be  found 
soft  and  pliable  and  composed  of  polypoid  masses.  Irregularities  in 
the  uterine  cavity  may  be  felt  if  the  cervix  is  open  sufficiently  to  admit 
the  finger.  The  diagnosis  may  be  made  from  uterine  scrapings  in  the 
majority  of  cases,  although  there  are  many  sarcomata  which  have  not 
yet  involved  the  endometrium  when  the  case  presents  for  treatment. 
Unfortunately,  the  diagnosis  is  usually  made  only  after  removal  of  the 
uterus. 

Prognosis. — The  prognosis  of  uterine  sarcoma  is  extremely  grave 
when  the  tumor  is  of  the  rapidly  growing  type.  Yet,  as  in  sarcoma  of 
other  organs,  it  varies  somewhat  according  to  the  histogenesis  of  the 
tumor.  Thus,  the  fibrosarcomata  occasionally  grow  so  slowly  that 
there  may  be  many  years  before  the  fatal  issue.  Gusserow  described 
a  case  of  more  than  ten  years'  duration.  The  average  duration  is 
usually  placed  at  three  years,  but  cases  may  earlier  come  to  fatal  issue. 
The  question  is  confused  because  many  cases  develop  in  fibroids  and  it 


CARCINOMA  AND  SARCOMA  OF  THE  UTERINE  BODY  299 

is  difficult  to  tell  when  the  sarcoma  begins.  The  round-cell  forms  are 
more  malignant,  as  a  rule,  than  the  other  types.  The  giant-cell  tumor 
is  the  least  malignant.  Grapelike  sarcoma  is  very  malignant. 

Treatment. — Radical  removal  of  the  uterus  and  appendages  is  im- 
perative in  the  presence  of  a  tumor  in  which  the  condition  is  suspected. 
This  suffices,  as  a  rule,  for  sarcomata  which  have  developed  and  are 
still  local  in  the  uterine  wall.  Other  types  of  the  tumor  should  be 
treated  by  the  abdominal  radical  method  described  for  cervical  car- 
cinoma. The  results,  unfortunately,  are  not  good.  There  are  com- 
paratively few  cases  of  simple  hysterectomy  which  have  not  been 
followed  by  recurrence.  Radium  treatment  should  give  better  results 
than  incomplete  operations.  When  recurrence  takes  place,  it  develops 
usually  with  astonishing  rapidity.'  The  great  majority  die  within  a 
year.  Gessner  reports  a  recurrence  following  a  radical  operation  in 
10  of  26  cases  originating  in  the  endometrium.  Sixteen  cases  were 
cited  as  cured,  although  only  5  had  been  observed  for  five  or  more 
years.  Recurrence  was  noted  in  14  of  35  cases  of  sarcoma  of  the 
uterine  wall.  The  remaining  21  were  accounted  as  cured,  although 
only  5  had  been  followed  for  five  years. 


LITERATURE 

CULLEN.    Cancer  of  the  Uterus.     1900. 
CROOM.     Eden  and  Lockyer.     Syst.  Gynec.     1917.     2:388. 
KELLY-CULLEN.    Myoma  of  Uterus.     1903. 
MEYER.     Monatschr.  f.  Geburtsh.     1911.     33:  701. 
MEYER,  R.    Veit's  Handbuch  der  Gynakologie. 
OFFERGELD.    Zentralbl.  f.  Gynak.     1909.    64:  i. 
PETERSON.     Surg.  Gynec.  &  Obst.     1916.    23:  237. 
SITZENFREY.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1910.    67:  32. 
TAYLOR.    Surg.,  Gynec.  &  Obst.    1907.    56. 
Surg.,  Gynec.  &  Obst.     1909.     59. 
WEIBEL.    Arch.  f.  Gynak.     1913.     100:  135. 
WERTHEIM.    Tr.  Internat.  Cong.  Med.,  Lond.     1913. 
WILSON.    Eden  and  Lockyer.    Syst.  Gynec.     1917.    2:  512. 
WILLIAMS.    Uterine  Tumors.     1901. 


CHAPTER   XI 
CHORIO-EPITHELIOMA 

Definition — Historical — Marchand's  theory — Classifications — Ewing — Geist  —  Frequency — 
Etiology — Hydatidiform  mole — Age — Location  of  growth — Period  of  latency  follow- 
ing pregnancy — Metastasis — Ovarian  changes — Symptoms — Diagnosis — Microscopic 
diagnosis — Differential  diagnosis — Prognosis — Treatment — Operation — Radium. 

CHORIO-EPITHELIOMA 

Chorio-epithelioma  is  a  very  malignant  tumor  which  invariably 
arises  in  connection,  either  immediate  or  remote,  with  a  pregnancy. 
It  develops  from  the  chorionic  villi  after  labor  at  full  term,  abortion, 
hydatidiform  mole,  and  occasionally  even  before  the  products  of  gesta- 
tion have  been  expelled  from  the  uterus.  It  arises  from  the  fetal  ecto- 
derm and  is  composed  of  varying  proportions  of  syncytial  and  Lang- 
hans'  cells  derivatives.  It  is  found  most  frequently  in  the  uterus  but 
has  been  described  in  the  tube  and  ovary.  These  tumors  attract  inter- 
est because  of  the  great  variation  in  their  malignancy,  since  some  kill  most 
quickly,  while  others  are  seemingly  benign.  The  frequent  lack  of 
coordination  between  the  clinical  and  pathological  findings  which 
makes  it  impossible  to  determine  before  the  tumor  has  run  its  course  as 
to  its  degree  of  malignancy,  and  the  fact  that  there  are  spontaneous 
cures  even  after  the  development  of  metastases,  the  recognition  of 
similar  histologic  appearances  in  teratoma,  all  tend  to  make  the  subject 
one  of  the  most  interesting  and  debatable  chapters  in  pathology. 

Historical. — The  fact  that  there  were  malignant  tumors  closely 
allied  with  pregnancy  and  hydatidiform  moles  was  recognized  in  fairly 
early  medical  literature,  yet  no  attempt  was  made  to  classify  them  until 
quite  recently.  As  early  as  1877,  Chiari  described  3  cases  which  he 
considered  atypical  carcinoma  which  developed  coincidentally  with 
pregnancy.  Sanger,  in  1889,  first  definitely  recognized  the  disease  as  a 
clinical  entity  and  classified  it  as  a  sarcoma  which  developed  only  in  a 
gravid  uterus.  Believing  that  the  decidua  was  the  site  of  the  neoplasm, 
he  termed  the  tumor  deciduoma  malignum.  Sanger's  view  obtained 
support  in  1890  by  Pfeiffer,  a  pupil  of  Chiari,  who  met  with  a  similar 
case  and  quite  independently  came  to  the  same  conclusion  and  gave  his 
tumor  the  same  name.  Pestalozzi,  in  1891,  described  3  cases,  although 
he  could  not  decide  as  to  their  cellular  origin.  Other  cases  were  soon 
reported  by  Schmorl,  Miiller,  Gottschalk.  and  Lebensbaum,  none  of 

300 


CHORIO-EPITHELIOMA  301 

whom  completely  accepted  Sanger's  views.  In  1893,  Sanger  reviewed 
the  subject  and  modified  his  views  to  some  extent,  although  holding 
the  conviction  that  the  essential  malignant  elements  of  the  tumor  were 
derived  from  decidual  cells  and  that  the  chorionic  elements  were 
merely  adventitious. 

Gottschalk,  in  1894,  first  advanced  the  theory  that  the  disease  was 
primary  in  the  fetal  tissue,  being  essentially  a  sarcoma  of  the  chorion, 
arising  from  the  Langhans'  layer,  which  was  then  regarded  as  fetal 
mesoblastic  tissue,  and  from  the  stroma  of  the  villi.  A  number  of  cases 
were  reported  in  the  same  year  by  others  without  advancing  new  views 
concerning  the  origin  of  the  tumor. 

Considerable  confusion  was  added  to  the  subject  because  of  the 
erroneous  views  which  existed  at  that  time  as  to  the  origin  of  the  syn- 
cytium  and  Langhans'  cells  layer.  The  majority  believed  that  the 
former  was  of  maternal  and  the  latter  of  fetal  origin.  No  firm  advocate 
that  the  syncytium  was  derived  from  fetal  ectoderm  had  yet  become' 
intensely  interested  in  this  type  of  tumor.  Whitridge  Williams,  in 
describing  his  tumor  in  1895,  recognized  its  connection  with  the  chori- 
onic epithelium  and,  although  he  described  the  importance  of  the 
Langhans'  cells,  he  considered  the  syncytium  as  the  more  essential 
element. 

Marchand's  Theory. — Marchand's  monograph  in  the  same  year 
(1895)  did  much  to  clear  up  the  subject  and  to  establish  the  pathology 
on  the  present  basis.  He  identified  the  tumor  cells  as  derivatives  of 
both  layers  of  the  chorionic  epithelium,  and  recognized  the  etiologic 
features  contributed  by  hydatidiform  mole.  The  subject  appeared 
most  confusing,  since  he  accepted  the  ruling  opinion  as  to  the  nature  of 
the  syncytium,  and  saw  the  tumor  as  of  mixed  maternal  and  fetal  origin. 
The  frequency  with  which  hydatidiform  mole  precedes  chorio-epitheli- 
oma  had  been  noted  by  previous  observers.  Some  had  sought  to  estab- 
lish a  causal  relationship  between  the  two.  Marchand,  however,  was 
the  first  to  recognize  the  true  pathology  of  hydatidiform  mole  as  an 
excessive,  irregular  proliferation  of  both  layers  of  the  chorionic  epi- 
thelium, together  with  the  degeneration  of  the  mesoblastic  cores  of  the 
placental  villi.  The  older  view  was  that  of  Virchow,  who  saw  in  the 
mole  only  a  myxorna  of  the  chorion.  Marchand  traced  a  very  close 
likeness  between  the  hypertrophied  epithelium  of  the  mole  and  the 
cells  of  the  chorio-epithelioma.  Not  only  were  the  cell  forms  similar, 
but  they  infiltrated  the  maternal  tissues  and  invaded  the  blood  vessels 
in  a  similar  way.  The  invasion  appeared  only  as  an  exaggeration  of  the 
conditions  found  about  the  attachment  of  the  villi  to  the  decidua  in  the 
young  placenta.  He  regarded  chorio-epithelioma  as  a  member  of  a 
series  of  diseased  conditions  of  the  chorionic  epithelium  which  showed 
many  varieties  and  a  progression  in  degree  of  malignancy  comparable 
with  that  seen  in  other  tumors,  such  as  the  cell  picture  seen  between 


3o2  PELVIC   NEOPLASMS 

simple  adenoma  and  malignant  adenoma,  and  simple  papilloma  and 
carcinoma.  He,  however,  considered  it  impossible  in  any  given  case 
to  distinguish  sharply  between  the  proliferation  seen  in  a  simple 
hydatidiform  mole  and  the  malignant  tumor. 

He  divided  the  malignant  chorionic  epithelioma  into  two  classes, 
typical  and  atypical,  between  which  were  certain  transitional  forms. 

The  typical  chorio-epithelioma  are  those  in  which  is  reproduced  the 
character  of  the  chorionic  epithelium  as  it  occurs  in  early  pregnancy, 
either  changed  or  with  little  alteration.  In  this  type,  syncytial  masses 
are  seen  in  the  well-known  form  of  irregular,  multinucleated  columns 
and  branching  protoplasmic  masses,  associated  with  more  or  less  well- 
developed  polyhedral  cells  of  the  Langhans'  layer. 

The  atypical  group  shows  invasion  of  the  musculature  of  the  uterus 
by  syncytial  masses  or  individual  giant  cells.  It  is  characterized  by  the 
absence  of  Langhans'  cells. 

In  the  transition  forms  between  these  two  types,  there  is  an  increas- 
ing proportion  of  syncytium  and  wandering  cells,  and  decrease  or 
absence  of  Langhans'  cells  as  compared  with  the  typical  tumors. 
Marchand  felt  that  the  two  types  did  not  differ  markedly  in  malig- 
nancy, although  the  typical  group  gave  rise  to  rapid  metastases 
through  the  blood  stream  while  the  atypical  forms  caused  more  local 
destruction. 

Marchand's  views  gradually  gained  general  acceptance.  Nearly  all 
authors  who  described  cases  after  1895  regarded  their  tumors  as 
derivatives  of  the  chorionic  epithelium,  while  the  observers  of  the 
older  cases  reexamined  their  tumors  and  retracted  their  former  opin- 
ions. It  was  not  until  1903,  however,  following  Teacher's  monograph, 
that  the  English  school  fully  accepted  Marchand's  teaching,  possibly 
because  the  English  were  chiefly  responsible  for  the  belief  that  syn- 
cytium was  altered  fetal  ectoderm. 

Attempts  at  Classification  Based  on  Histologic  Picture. — In  spite 
of  the  great  progress  in  the  histologic  knowledge  of  the  disease,  as 
reports  of  cases  multiplied,  it  became  more  and  more  apparent  that  the 
relation  between  the  histologic  structures  and  the  clinical  prognosis 
was  most  uncertain,  and  that  many  curious  features  of  these  growths, 
especially  the  spontaneous  recovery  of  apparently  hopeless  cases,  were 
wholly  unparalleled  by  any  other  malignant  neoplasm.  Von  Velits 
was  the  first  to  maintain  that  the  more  benign  growths  presented 
definite  histologic  features,  such  as:  (i)  absence  of  mitosis  in  Lang- 
hans' cells;  (2)  degenerated  areas  in  both  cell  derivatives;  and  (3) 
comparative  or  complete  absence  of  Langhans'  cells.  Schmauch  also 
emphasized  the  relation  between  the  Langhans'  cell  derivatives  and 
the  degree  of  malignancy.  He  saw  the  malignant  type  only  as  a  cellular 
infection  of  the  organism  by  derivatives  of  chorionic  epithelium. 
While  there  is  wide  dissemination  of  chorionic  cells  as  a  physiologic 


CHORIO-EPITHELIOMA  303 

process  during  pregnancy,  the  normal  protective  powers  of  the  female 
organism  prevent  their  proliferation.  The  latter  phenomena  is  pos- 
sible, therefore,  only  in  the  absence  of  cytolytic  forces.  Schmauch  dif- 
fered from  Marchand  only  in  that  he  saw  that  the  literature  indicated 
that  nearly  all  cases  which  died  of  general  metastases  were  of 
Marchand's  group  of  typical  chorio-epithelioma.  While  the  transitional 
types  might  kill,  the  greater  number  gave  only  metastases  in  the  lungs 
without  generalization.  He  stated  that  not  one  case  of  generalized 
metastases  in  an  atypical  chorio-epithelioma  had  been  reported. 
Others,  as  R.  Meyer,  and  Schlagenhaufer,  also  attempted  to  establish 
definite  histologic  .criteria  without  definite  results. 

In  1910,  Ewing  made  a  more  elaborate  histologic  classification  than 
that  of  any  previous  author,  attempting  to  separate  the  malignant  from 
the  semibenign  tumors  on  the  basis  of  histologic  appearance  and  thus 
to  establish  a  more  definite  criterion  for  treatment.  He  divided  the 
typical  chorio-epithelioma  of  Marchand  into  (a)  benign  chorio-adenoma ; 
and  (&)  the  very  malignant  choriocarcinoma. 

The  chorio-adenoma,  previously  known  as  malignant  placental 
polyp,  is  composed  of  elongated  hypertrophied  villi,  the  margins  of 
which  are  covered  with  actively  proliferating  cells  of  both  types  of 
fetal  epithelium.  These  villi  infiltrate  the  uterine  sinuses,  usually  over 
a  large  area,  enlarge  the  uterus  uniformly  and  often  project  as  a 
polypoid  mass  into  the  uterine  cavity.  They  tend  to  remain  long  con- 
fined within  the  uterine  cavity  or  wall,  although  occasionally  they 
invade  the  broad  ligament  and  pelvic  veins  and  give  metastases  con- 
taining villi  to  the  vagina  or  the  lungs,  but  rarely,  if  ever,  give  rise  to 
general  metastases.  The  tumor  reproduces  in  a  rather  orderly  fashion 
all  the  structures  of  a  normal  villus  without  metaplasia  or  morphologic 
variations  from  the  normal  type  of  cell,  although  an  entire  villus  may 
not  necessarily  be  present  in  each  individual  specimen  presented  for 
examination. 

The  course  of  chorio-adenoma  resembles  in  many  respects  that  of 
the  more  malignant  chorioma,  but  differs  in  certain  essential  features. 
It  tends  to  produce  greater  enlargement  .of  the  uterus,  often  with 
polypoid  tumors  distending  the  cavity,  and  usually  perforates  that 
organ  but  slowly,  and  does  not  necessarily  extend  into  the  pelvic  veins. 
It  may  be  cured  by  curetting,  or  by  partial  removal,  and  perhaps  by 
spontaneous  expulsion,  results  not  observed  with  more  malignant 
tumors.  Though  it  produces  metastases,  they  are  likely  to  be  limited 
in  extent  and  may  undergo  spontaneous  retrogression,  a  feature  almost 
unknown  in  choriocarcinoma. 

The  malignant  choriocarcinoma  of  Ewing  exhibits  a  very  different 
structure.  There  are  absence  of  villi,  but  a  very  extensive  proliferation  and 
pronounced  metaplasia  of  both  Langhans'  cells  and  syncytium.  The  tumor 
cells  exhibit  a  remarkable  capacity  for  independent  growth;  in  metastases, 


304  PELVIC  NEOPLASMS 

they  present  a  striking  lack  of  differentiation.  They  grow  diffusely  with- 
out the  orderly  arrangement  or  polarity  seen  in  the  milder  forms  of  chori- 
onic  tumors.  The  primary  tumor  of  the  uterus  is  comparatively  small,  and 
does  not  enlarge  the  organ,  yet  numerous  metastases  may  be  found  in  lungs, 
spleen,  brain  and  other  organs.  As  indicated  by  the  histology,  the  cancer  is 
of  high  potential  malignancy  and  it  is  doubtful  whether  any  cases  purely 
of  this  type  have  recovered.  Ewing  admits  the  possibility  of  intermediate 
forms  between  his  two  types  of  chorio-adenoma  and  choriocarcinoma. 

The  atypical  chorio-epithelioma  of  Marchand  is  divided  by  Ewing  into 
two  groups:  (a)  syncytioma;  and  (b)  syncytial  endometritis.  The  local 
uterine  growth  is  not  clearly  defined  in  these  forms  as  in  the  chorio-adenoma 
and  choriocarcinoma.  In  its  place,  there  is  a  bulky  mass  which  may  fill  the 
cavity  and  enlarge  the  organ,  composed  of  uterine  stroma  infiltrated  with 
large  or  giant  acidophil  cells  of  the  general  type  of  syncytial  wand-ering 
cells.  Mingled  with  these  is  much  fibrin  and  necrotic  detritus,  and 
the  mass  is  swollen  by  exudate  and  hemorrhage.  The  size  of  the 
primary  growth  may  vary  and  may  be  limited  to  a  small  area  of 
the  mucosa  or  infiltrate  the  entire  wall.  Rarely  it  extends  through 
the  wall  into  the  broad  ligaments.  Progressive  metastases  have 
not  been  observed  according  to  Ewing,  but  Fleischmann  has  described  a 
vaginal  tumor  presenting  the  structure  of  these  atypical  chorioma  which 
may  have  arisen  from  deported  villi.  This  group  of  syncytioma  prob- 
ably arise  as  retrogressive  processes  from  one  of  several  antecedent 
factors,  chiefly  abortion,  hydatidiform  mole,  or  chorio-adenoma ;  prob- 
ably choriocarcinoma  never  undergoes  such  extensive  retrogressive 
changes.  When  the  syncytial  cells  are  abundant,  well  nourished,  and 
form  more  or  less  compact  sheets,  a  neoplastic  quality  is  suggested  and 
the  term  "syncytioma"  may  be  employed.  When  the  lesion  is  more 
diffuse  and  complicated  by  exudative  and  productive  inflammation,  it 
seems  best  designated  as  syncytial  endometritis. 

The  prognosis  in  syncytiomata  is  essentially  favorable,  since  the 
process  advances  slowly  and  the  life  of  the  wandering  cells  is  short. 
Early  warnings  are  given  by  hemorrhages  and  enlargement  of  the 
uterus,  and  progressive  metastases  apparently  have  not  been  observed. 
Yet  the  disease  is  not  without  danger  and  many  cases  are  fatal.  In 
Schmauch's  list,  5  per  cent  of  his  fatal  cases  were  syncytiomata.  Hem- 
orrhage, local  and  general  infection,  peritonitis,  and  perforation  of  the 
uterus  during  curetting,  are  the  chief  causes  of  death. 

Geist  is  the  latest  author  to  attempt  to  correlate  the  histologic  picture 
with  the  prognosis  and  the  type  of  treatment  indicated.  He  agrees 
with  Ewing  that  Marchand's  atypical  chorio-epithelioma  is  essentially 
benign,  although  it  may  be  fatal  from  accidental  complications.  He 
regards  Ewing's  syncytial  endometritis  as  neither  a  true  tumor  nor  an 
inflammation,  but  rather  as  an  exaggeration  of  the  normal  process  of 
invasion  of  the  uterine  muscle  by  syncytial  cells.  He  believes,  there- 


CHORIO-EPITHELIOMA  3°5 

fore,  that  it  is  more  accurately  designated  as  a  syncytial  hyperplasia. 
In  Ewing's  syncytioma,  he  sees  a  transition  between  the  syncytial 
hyperplasia  and  the  more  advanced  forms  of  the  chorioma,  and  con- 
siders it  the  first  real  step  of  a  true  neoplasm.  He  believes  that  it  is  not 
a  retrogressive  and  degenerating  chorio-epithelioma  in  which  all  the 
Langhans'  elements  have  disappeared,  as  does  Ewing,  but  considers  it 
a  growth  composed  of  one  definite  cell  type.  Geist  does  not  believe 
that  it  is  possible  to  subdivide  Marchand's  typical  chorio-epithelioma 
into  semibenign  and  malignant  type  in  accordance  with  Ewing's  view 
of  chorio-adenoma  and  choriocarcinoma.  He  agrees  rather  with 
Schlagenhaufer,  Marchand,  Aschoff,  Hitschmann,  and  Cristofoletti 
that,  histologically,  we  cannot  obtain  evidence  sufficiently  definite  to 
be  of  prognostic  value.  He  admits  that  cases  presenting  all  the  histo- 
logic  features  of  malignancy,  such  as  invasion  of  the  musculature  by 
large  cell  masses,  mitotic  figures  in  Langhans'  cells,  leukocytic  reac- 
tion, necrosis,  thrombosis,  and  invasion  of  vessels  may  have  a  perfectly 
benign  course.  On  the  other  hand,  cases  which  histologically  appeared 
more  benign  in  which  there  was  absence  of  mitosis  and  other  indica- 
tions of  malignancy,  have  progressed  to  fatal  issue.  Geist  believes  that 
there  are  so  many  transition  forms  between  Ewing's  classification  of 
chorio-adenoma  and  choriocarcinoma  that  it  is  impossible  to  diagnose 
positively  by  histologic  means  a  benign  type,  since  the  tissues  exam- 
ined may  not  be  typical  of  all  the  phases  that  are  present.  Geist 
further  admits,  while  Ewing  will  not,  that  there  are  cases  of  truly 
malignant  choriocarcinoma  which,  -although  present  with  metastases, 
have  retrogressed  spontaneously  or  after  incomplete  operations. 
Geist's  conception  seems  to  be  that  of  the  majority  of  the  pathologists 
at  the  present  time.  Whether  further  experience  with  clinical  data 
and  exact  microscopic  descriptions  will  allow  us  to  accept  Ewing's 
more  detailed  classification  with  its  endeavor  for  a  more  accurate  prog- 
nosis, remains  for  the  future  to  decide. 

Frequency. — Chorio-epithelioma,  when  first  described,  was  consid- 
ered a  disease  of  great  rarity.  Case  reports,  however,  soon  multiplied 
so  that  Teacher,  in  1902,  was  able  to  collect  188  well-authenticated 
cases.  He  knew,  however,  of  many  others  which  had  not  been  pub- 
lished, since  he  saw  the  slides  of  numbers  of  unrecorded  cases  in 
Prague  and  Dresden,  Kiel  and  Leipzig.  The  incidence  of  the  disease 
varies  in  different  countries  and  at  different  times.  In  the  eighteen 
months  from  February,  1901,  to  August,  1902,  7  cases  were  found  in 
the  2,700  autopsies  at  the  General  Hospital  in  Vienna;  yet  in  Budapest, 
where  the  pathologists  were  searching  for  such  cases  for  several  years, 
not  one  instance  was  reported.  Teacher  pointed  out  that  in  London, 
with  more  than  twice  the  population  of  Vienna,  only  7  cases  were 
recorded  and  very  few  from  other  parts  of  England.  This  he  attributed 
to  the  rarity  of  post-mortem  examinations  in  England  and  to  the  chance 


306  PELVIC   NEOPLASMS 

that  many  cases  were  incorrectly  diagnosed  as  retained  placenta, 
sepsis,  or  sarcoma.  Pollosson  and  Violet,  in  1913,  carefully  tabulated 
the  collected  cases  and  were  able  to  add  238  to  Briquel's  217  collected 
cases  (1903),  making  in  all  a  total  of  455  cases.  In  1917,  Vineberg 
added  78  more  cases,  including  7  of  his  own.  Sunde,  in  1919,  collected 
38  cases  in  Christinia.  Since  then,  isolated  cases  only  have  been 
reported  in  the  literature.  A  review  of  the  material  unreported  during 
the  period  of  the  war  may  add  greatly  to  the  list. 

Etiology. — Like  malignant  tumors  in  general,  the  true  etiology  is 
unknown.  We  know,  however,  that  with  few  exceptions,  pregnancy 
has  preceded  the  growth;  it  is,  therefore,  a  disease  essentially  of  fertile 
women.  The  frequency  of  the  disease  runs  parallel  with  the  degree  of 
fertility.  Ladinski,  in  an  analysis  of  90  cases,  found  an  average  of  4.2 
pregnancies.  Briquel,  studying  158  cases,  found  33,  or  21  per  cent, 
with  the  second  pregnancy,  31,  or  20  per  cent,  with  the  third,  and  74,  or  47 
per  cent  with  the  fourth  or  more.  Olivier  Bauregard  found  that,  of  178 
cases,  66  had  borne  more  than  five  children,  whereas  only  22  were  nullipara. 
Various  conditions  have  been  suggested  as  predisposing  factors,  such 
as  diminished  resistance  because  of  too  frequent  pregnancies,  previous 
inflammatory  conditions  of  the  endometrium,  and  defective  formation 
of  the  decidua,  especially  in  Nitabuch's  fibrin  layer.  On  the  other 
hand,  so  many  patients  had  enjoyed  perfect  health  up  to  the  fatal  preg- 
nancy that  it  seems  unjustifiable  to  regard  preceding  ill  health  as  an 
important  factor.  Yet  recently,  Fink  felt  that,  in  his  case,  as  in  the 
older  case  of  Lindfors,  a  severe  attack  of  influenza  during  the  preg- 
nancy may  have  diminished  the  resistance  and  have  made  it  possible 
for  the  malignant  elements  to  gain  the  upper  hand.  Yet  it  seems  more 
reasonable  to  accept  the  view  of  a  primary  fetal  cause  that  the  tropho- 
blasts  have  an  unusual' activity  which  permits  them  to  retain  embryonic 
power  of  growth  to  the  end  of  pregnancy  and  often  for  a  much  longer 
period. 

Pollosson  and  Violet  studied  the  character  of  the  pregnancy  pre- 
ceding the  disease  in  455  cases.  Two  hundred  and  three  cases,  or  45 
per  cent,  followed  a  hydatidiform  mole.  One  hundred  and  thirty-five 
cases,  or  30  per  cent,  followed  abortion.  Ninety-nine  cases,  or  21  per 
cent,  followed  labor  at  term.  Twelve  cases,  or  2.5  per  cent,  followed 
ectopic  gestation.  In  6,  the  character  of  the  previous  pregnancy  was 
doubtful.  The  great  majority  of  their  cases,  therefore,  followed  an 
abnormal  pregnancy,  yet  21  per  cent  followed  delivery  at  term,  and  a 
pregnancy  that  had  appeared  normal. 

Hydatidiform  mole  antedates  so  many  cases  that  it  must  be  con- 
sidered as  an  important  predisposing  condition.  We  are  ignorant, 
however,  of  the  percentage  of  cases  of  hydatidiform  mole  that  are 
followed  by  chorio-epithelioma.  In  Palmer  Findley's  first  series  of 
210  hydatidiform  moles,  16  per  cent  were  known  to  become  malignant 


CHORIO-EPITHELIOMA  307 

later.  In  his  series  of  500  cases,  31.4  per  cent,  or  157  cases,  were  fol- 
lowed by  chorio-epithelioma.  But  Findley  calls  attention  to  the  fact 
that  ordinary  benign  moles  are  not  reported,  while  those  which  undergo 
malignant  changes  are  recorded  with  greater  frequency.  Senarclans 
found  that  of  49  hydatidiform  moles,  chorioma  developed  subsequently 
in  3,  or  6  per  cent,  while  4  others  died  of  other  complications.  Hitsch- 
mann  and  Cristofoletti,  in  200  cases  of  hydatidiform  mole,  found  that 
7.5  per  cent  were  followed  by  chorio-epithelioma. 

Our  conception  of  the  frequency  of  hydatidiform  degeneration  of 
the  chorion  has  been  materially  changed  by  the  work  of  Arthur  Meyer, 
who  found,  on  gross  examination,  8  such  cases  in  the  first  2,089  uterine 
abortions  in  the  Mall  collection,  or  one  in  261 ;  careful  microscopic 
examination  showed  a  much  higher  proportion.  These  findings  justify 
his  conclusion  that  hydatid  degeneration  is  not  uncommon  in  early 
abortions.  Later,  it  appears  more  rarely  as  former  statistics  would 
indicate.  Madame  Boivin,  in  1827,  found  i  mole  in  20,000  pregnancies; 
Williamson,  in  1900,  i  in  2,400;  Pozzi  met  with  none  in  6,000  cases; 
Mayer,  in  1911,  in  3,105  pregnancies,  found  10  cases;  Essen-Miiller,  in 
6,000  cases,  found  a  proportion  of  i  to  333  cases.  We  have  met  but  I 
case  in  the  last  3,600  pregnancies.  Yet,  in  view  of  Arthur  Meyer's 
findings,  fewer  moles  are  the  forerunners  of  chorio-epithelioma  than 
has  generally  been  considered,  since  the  type  which  he  studied  showed 
a  decided  tendency  to  abort  completely  at  a  very  early  period  in  preg- 
nancy. 

Age. — The  age  of  cases  presenting  chorio-epithelioma  ranges  from 
seventeen  to  fifty-eight  years  in  cases  reported  in  the  literature. 
Teacher,  in  188  collected  cases,  found  thirty-three  years  as  the  average 
age.  Fifty-seven  per  cent  of  his  series  occurred  between  twenty  and 
forty  years.  There  were  6  cases  under  twenty  years  and  9  cases  over 
fifty  years.  In  Vineberg's  collection  of  78  cases,  4  were  less  than 
twenty  and  8  were  over  fifty  years.  A  number  of  cases  which  occurred 
younger  than  twenty  years  and  older  than  fifty  years  were  thought  to 
have  followed  hydatidiform  mole,  which  is  often  met  with  at  the 
extremes  of  fertile  life. 

Location  of  Growth. — In  nearly  all  cases,  the  tumor  has  been  found 
located  in  the  uterine  cavity.  There  are,  however,  undoubted  cases  of 
primary  ectopic  chorio-epithelioma.  The  latter  group  have  been  found 
chiefly  in  the  tubes  and  vagina.  There  is  some  question  as  to  whether 
it  may  arise  in  the  ovary,  as  an  extraplacental  tumor. 

Tubal  pregnancy  has  given  rise  to  chorio-epithelioma  in  21  reported 
cases.  Twelve  of  these  were  reported  by  Risel  in  1905  and  to  this  list 
has  been  added  i  case  by  Garkisch,  7  by  Liepmann  in  1914,  and  i  by 
Hartz  in  1916.  All  of  these  cases  were  discovered  either  at  operation 
or  at  autopsy.  The  diagnosis  is  based  upon  the  presence  of  a  tumor 
distending  the  tube  or  broad  ligament  and  lying  wholly  outside  the 


3o8  PELVIC   NEOPLASMS 

uterus  and  with  a  uterine  mucosa  which  is  unaffected.  The  mass  has 
varied  in  size  from  that  of  a  hen's  egg  to  that  of  an  adult  head.  The 
tumor  is  very  friable  and  exceedingly  hemorrhagic  and  presents  a  gross 
appearance  identical  with  that  of  tumors  which  are  primary  in  the 
uterine  cavity.  The  histologic  features  are  also  identical  with  the 
growths  primary  in  the  uterus.  Metastases  are  very  frequent.  The 
tumor  seems  to  have  a  more  rapid  course  and  to  metastasize  more 
quickly  than  does  chorio-epithelioma  of  the  uterus.  Albert's  case  and 
that  of  Hartz  are  the  only  ones  which  recovered. 

There  are  a  number  of  tumors  which  have  been  described  both  in 
the  testicle  and  in  the  ovary  which  have  presented  structures  identical 
with  those  of  chorio-epithelioma  without  evidence  of  teratomatous 
features.  They  are  now  usually  considered  as  teratoma,  although  for 
a  time  they  threatened  to  overthrow  our  ideas  concerning  the  sig- 
nificance and  mode  of  origin  of  chorio-epithelioma.  They  were  first 
explained  on  the  ground  that  fetal  membranes  had  been  included  in 
the  teratoma  which  proliferated  only  after  lying  dormant  for  many 
years.  Nearly  all  investigators  now  accept  the  view  of  Risel  that 
such  an  assumption  is  unnecessary,  since  such  a  tumor  may  develop 
from  undifferentiated  fetal  ectoderm  present  in  the  teratomatous 
growth. 

Waldeyer,  in  1868,  described  a  polypoid  tumor  mass  suggesting  a 
hydatidiform  mole  which  extended  from  a  testicular  teratoma  into  the 
pelvic  veins.  Breus,  in  1878,  described  a  similar  case  in  which  the 
polypoid  masses  extended  into  the  heart.  There  are,  in  the  French 
literature,  a  number  of  similar  cases  described  under  the  term  "sarcoma 
angioplastique"  recorded  by  Malassez  and  Monod,  Carnot  and  Marie, 
and  others  who  also  noted  the  resemblance  to  hydatidiform  mole. 
McCallum  observed  a  similar  case  which  he  interpreted  as  lymphendo- 
thelioma.  Wlassow  and  Schlagenhaufer,  however,  were  the  first  to 
emphasize  the  resemblance  of  this  type  of  tumor  to  the  chorio- 
epithelioma.  Their  report  made  a  profound  sensation  and  has  been 
the  cause  of  much  investigation.  Their  case  presented  a  teratoma  of 
the  testicle  which  had  given  off  generalized  metastases  and  was  com- 
posed of  syncytium,  Langhans'  cells  and  occasional  structures  suggest- 
ing chorionic  villi.  They  traced  the  origin  of  the  syncytial  masses  to 
the  epithelium  of  the  testicular  growth,  identified  the  Langhans'  cells 
and  described  glycogen  in  them,  noted  the  hemorrhagic  character  of 
the  metastases,  and  showed  that  this  chorioma  of  the  testicle  repro- 
duced almost  exactly  the  essential  features  of  chorio-epithelioma  of  the 
uterus. 

Similar  processes  have  been  noted  in  the  ovary  where,  of  course, 
there  is  the  possibility  that  the  tumor  followed  an  ovarian  pregnancy. 
The  reported  cases  are  few  in  comparison  with  those  of  chorioma  testis. 
Pick  early  described  a  case  which  reproduced  the  gross  features  and 


CHORIO-EPITHELIOMA  309 

microscopic  picture  of  a  primary  chorio-epithelioma  of  the  uterus.  The 
mass  was  composed  of  syncytial  and  Langhans',  cells  derivatives,  to- 
gether with  a  sarcomatous  framework.  The  syncytial  masses  were 
traced  to  a  neuro-epithelial  cell  group,  invaded  the  vessels  and  added 
a  hemorrhagic  character  to  the  tumor.  The  growth  contained  many 
small  polyhedral  cells  of  the  Langhans'  type  which  presented  many 
mitoses  and  contained  glycogen.  The  mass  also  presented  glandular 
areas  lined  with  mucous  cells  in  a  sarcomatous  framework.  Emil  Ries, 
in  1915,  reported  I  case  and  collected  6  others  from  the  literature,  all 
of  which  presented  as  primary  chorioma  of  the  ovary  without  evidence 
of  other  teratomatous  structures.  Ries  carefully  reviewed  the  various 
possibilities  concerning  the  origin  of  his  tumor:  (i)  it  might  have 
been  of  teratomatous  origin;  (2)  a  metastases  from  a  chorioma  primary 
in  the  placenta  which  was  expelled  completely  during  labor;  (3)  it 
might  have  developed  from  fetal  cells  which  were  deported  from  a 
normal  placenta  and  which  did  not  assume  malignant  character  until 
it  reached  the  ovary;  and  (4)  it  might  have  arisen  from  an  ovarian 
pregnancy. 

There  are  also  a  number  of  cases  which  have  been  described  as 
primary  ectopic  chorio-epithelioma  in  locations  remote  from  the  vari- 
ous possible  placental  sites,  and  in  which  it  was  impossible  to  trace 
a  direct  anatomic  connection  between  the  growth  and  any  site  of  an 
intra-uterine  or  extra-uterine  pregnancy.  Palmer  Findley,  in  1904, 
collected  21  such  cases  and  since  then  many  others  have  been  added. 
The  uterine  mucosa  is  always  free  from  involvement,  although  it  may 
contain  typical  decidual  alteration.  The  endometrium  in  the  cases  of 
Schmorl,  Fiedler,  and  Holzapfel  averaged  .8  centimeter  in  thickness 
and  resembled  a  decidua  vera  of  normal  pregnancy.  It  seemed  anal- 
ogous to  the  decidual  formation  of  ectopic  pregnancy.  The  entire  group  is 
composed  of  cases  where  the  lesion  could  be  directly  inspected,  that  is, 
in  the  vagina,  labium  and  cervix.  The  clinical  diagnosis  was  at  all 
times  confirmed  by  microscopic  examinations  of  tissue  curetted  from 
the  uterus.  While  much  has  been  written  concerning  these  primary 
ectopic  chorio-epithelioma,  nearly  all  agree  that  they  are  but  metas- 
tases which  developed  a  considerable  time  after  the  primary  growth, 
which  was  situated  in  a  placenta,  or  in  a  hydatidiform  mole,  which  liad 
been  expelled  from  the  uterus.  There  is  also  the  possibility  alluded  to 
before  that  these  so-called  primary  ectopic  chorioma  develop  from 
embolic  cells  in  a  normal  placenta  which  assume  malignant  properties 
only  after  they  have  been  arrested  after  being  deported.  Not  all,  how- 
ever, accept  these  possibilties,  since  there  is  a  chance  that  some  of  the 
growths  considered  as  primary  ectopic  choriomata  of  the  tubes, 
ovaries,  and  other  organs  were  not  derived  from  either  teratomatous 
sources  or  products  of  gestation.  Risel,  when  reviewing  the  subject, 
stated  that  many  of  the  tumors  on  record  might  well  be  metastases 


3 io  PELVIC   NEOPLASMS 

from  carcinoma  or  sarcoma  whose  secondary  metastases  developed  an 
atypical  structure.  Others,  however,  believe  that  Risel's  restrictions 
were  too  rigid  and  claimed  that  the  heterotopic  chorio-epithelioma  in 
both  sexes  present  identical  histology  with  chorio-epithelioma  which 
are  primary  in  the  uterus,  whereas,  the  choriomalike  structures  devel- 
oping in  metastases  from  carcinoma  or  sarcoma  present  varying 
appearances  and  only  a  few  resemble  chorio-epithelioma.  All  agree 
that  a  proper  diagnosis  cannot  be  made  from  fragments  of  tissues  since 
microscopic  resemblances  may  be  very  misleading. 

Period  of  Latency  Following  Pregnancy. — The  period  of  latency, 
or  the  period  elapsing  between  the  last  pregnancy  and  the  development 
of  the  disease,  is  most  variable,  and  has  ranged  from  a  few  weeks  to 
several  years.  The  longest  interval  stated  is  thirty-one  years  (Palthauf 
and  Polosson).  The  interval  is  often  from  three  to  four  years;  in 
Caturani's  case  it  was  five  years,  and  in  Polano's  case,  ten  years.  Many 
investigators  doubt  the  accuracy  of  the  long  period  of  latency  and 
assume  that  an  early  abortion  has  been  overlooked.  Yet  there  are  a 
number  of  cases  which  must  be  accepted  where  the  interval  was  at 
least  five  years.  One  of  these  was  reported  by  Kroesing.  The  patient 
was  fifty-two  years  of  age.  Five  and  a  half  years  before,  a  hydatidi- 
form  mole  had  been  removed.  Two  and  a  half  years  later,  both  ovaries 
were  removed.  At  this  time,  the  uterus  was  perfectly  normal.  Follow- 
ing the  operation,  there  was  complete  amenorrhea.  Three  and  a 
quarter  years  later,  or  five  and  a  half  years  after  the  hydatid,  the  uterus 
was  removed  for  metrorrhagia  and  was  found  to  be  the  seat  of  chorio- 
epithelioma. 

The  observation  of  Emil  Ries  suggests  that  a  villus  may  preserve 
its  identity  in  the  uterus  for  many  years.  In  studying  a  uterus  which 
he  had  removed  for  fibroids  from  a  woman  who  had  not  been  pregnant 
for  eighteen  years,  he  noticed  a  long  threadlike  formation  several 
inches  long  in  the  uterine  cavity,  attached  to  blood  sinuses  in  the  left 
uterine  horn.  Microscopic  examination  showed  that  these  filaments 
had  histologic  structures  identical  with  those  of  chorionic  villi,  except 
that  the  investigator  was  not  able  to  convince  himself  that  the  cellular 
covering  was  syncytium.  The  masses  did  not  arise  from  the  muscular 
coat  of  the  blood  vessels  but  penetrated  them.  They  were  not,  in  con- 
sequence, "vein  myoma."  The  longer  filaments  presented  the  outline 
of  primary  chorionic  stalks  of  early  pregnancy,  save  that  they  were  two 
or  three  times  as  long.  Others,  who  casually  studied  his  sections, 
thought  that  they  could  discern  a  double  layer  of  fetal  ectoderm. 
While  there  may  be  some  doubt  concerning  the  nature  of  the  epithelial 
covering,  that  is,  whether  it  was  covered  with  altered  endothelium  of 
the  veins,  there  is  no  question  but  that  there  was  no  proliferation  of  the 
cells.  Lack  of  this  phenomena  may  explain  the  failure  of  the  mass  to 
develop  into  a  typical  chorio-epithelioma. 


CHORIO-EPITHELIOM  A  3 1 1 

There  is  no  doubt  but  that,  in  many  cases,  with  a  latent  period  of 
a  few  weeks,  that  the  growth  was  present  before  the  pregnancy  was 
ended.  Vineberg  found  a  chorio-epithelioma  in  the  uterus  when 
exploring  the  cavity  of  that  organ  with  his  finger,  immediately  after 
removing  a  hydatidiform  mole.  Similar  cases  have  been  reported  by 
Eden,  Kelly,  and  Workman.  In  Pick's  case,  a  chorio-epithelioma  was 
observed  to  develop  in  the  vagina  during  the  fourth  month  of  gesta- 
tion, while  the  uterus  still  contained  a  hydatidiform  mole.  Wallart 
found  a  metastatic  growth  in  the  eighth  month  of  pregnancy  and 
metastatic  nodules  in  the  vagina  have  been  observed  while  the  uterus 
still  contained  a  hydatidiform  mole  (von  Rosthorn,  Poten,  and  Vass- 
mer).  Branson  observed,  during  labor  at  the  eighth  month,  what 
appeared  to  be  a  chorio-epithelioma.  The  mass  was  attached  to  the 
external  os  and  part  of  it  broke  away  when  he  introduced  the  forceps. 
The  patient  had  complained  of  symptoms  suggestive  of  cerebral  metas- 
tases  for  some  time  before  delivery.  She  died  a  few  days  after  labor. 
There  was  no  autopsy.  Fink's  case  presented  symptoms  so  shortly 
after  labor  at  the  thirty-sixth  week  that  he  thinks  that  the  tumor  was 
present  before  delivery.  There  are  similar  cases  in  the  literature 
which  substantiated  his  belief.  Fink's  patient  had  a  severe  post-partum 
hemorrhage  following  a  spontaneous  separation  of  placenta.  There 
was  more  than  normal  lochia  during  the  puerperium.  The  uterus 
appeared  subinvoluted.  Bleeding  recurred  on  the  eighteenth  day  and 
two  days  later,  he  removed  a  polypoid  growth  with  the  curette  which 
was  found  to  be  suspicious  of  chorio-epithelioma.  Bovee  found  an 
early  chorioma  in  a  two-month  chorion  in  a  uterus  which  he  removed 
for  degenerating  fibromyoma. 

Metastases. — Metastases  in  chorio-epithelioma  occur  in  nearly  all 
cases.  They  appear  at  a  varying  period  and  sometimes  occur  at  a  very 
early  stage.  Thus,  Poten  and  Vassmer  excised  2  vaginal  tumors 
(metastases)  five  days  before  the  primary  tumor  was  detected  in  the 
uterus.  Metastases  usually  takes  place  through  the  blood  current, 
which  is  explained  by  the  tendency  of  fetal  ectodermal  cells  to  erode 
and  penetrate  the  blood  vessels  with  which  they  come  in  contact.  Gen- 
eral metastases  result  from  fragments  of  the  neoplasm  which  invade 
the  blood  vessels  and  are  carried  to  the  heart,  and  thence  to  the  lungs 
from  which  it  is  disseminated  to  all  the  organs.  Metastases  to  the 
organs  of  the  genital  tract  develop  from  cell  structures  which  pass 
through  the  venous  anastomosis  of  the  pelvic  organs.  Nearly  all 
organs  of  the  body  have  been  the  seat  of  metastases. 

Metastases  in  the  lungs  are  most  frequent.  They  vary  much  in 
number  and  size.  Occasionally,  only  one  tumor  is  found  which  may 
acquire  very  large  dimensions;  more  frequently,  numerous  small 
nodules  are  scattered  throughout  the  entire  lung.  The  apices  and 
bases  are  commonly  involved  and  the  middle  lobes  less  frequently. 


312 


PELVIC   NEOPLASMS 


The  secondary  growths  may  develop  insidiously  and  give  no  evidence 
of  their  presence  until  found  at  autopsy.  More  frequently,  they  cause 
hemoptysis,  dyspnea  and  pain  in  the  chest.  Quite  naturally,  the  symp- 
toms are  dependent  upon  the  site,  number  and  size  of  the  secondary 
growths.  The  cases  of  Lindfors  and  Morison  presented  metastases  of 
enormous  size.  Quite  often,  the  lung  is  fairly  riddled  with  the  growths. 


FIG.  68. — CHORIOEPITHELIOMA.  A  chorio-adenoma  developing  shortly  after  the  removal  of 
a  hydatidiform  mole.  The  growth  has  invaded  the  uterus  and-  does  not  present  as  a 
polyp.  The  extension  into  the  broad  ligament  is  most  marked  on  the  right  side  where 
vesicular  masses  may  be  seen  invading  even  the  tube  and  ovary.  (Case  and  illustration 
through  courtesy  of  Dr.  Harold  Brunn.) 

Next  to  the  lungs,  the  vagina  and  vulva  are  most  commonly 
involved.  Because  of  their  situation,  they  are  the  most  easily  dis- 
cerned. Occasionally,  a  single  isolated  tumor  only  is  present.  More 
frequently,  there  are  numerous  small  nodules  which  may  almost 
coalesce  and  nearly  form  a  ring.  Their  form  and  size  vary  almost  as 
much  as  their  location.  They  may  involve  the  entire  vaginal  cana* 


CHORIO-EPITHELIOMA  313 

or  they  may  occur  only  at  the  vulvar  orifice  or  in  the  folds  of  the  labia 
majora.  They  often  occur  as  small  nodular  masses  beneath  the  mucosa, 
characterized  by  brown  or  violet  discoloration.  They  have  been  lik- 
ened to  thrombosed  varices  which  they  resemble  so  closely  as  to  be 
mistaken  frequently  for  them.  The  consistency  is  tense  and  elastic, 
almost  fluctuating  at  times.  Metastases  in  these  areas  grow  very 
rapidly,  cause  necrosis  and  irregular  ulcerations.  The  latter  are 
usually  clean  cut  and  well  defined,  but  soon  cause  profuse  and  obstinate 
hemorrhage  and  become  infected.  They  then  give  rise  to  a  sanguinous, 
fetid  discharge.  The  time  at  which  metastases  appear  varies  consider- 
ably. Usually  they  occur  late  in  the  disease,  often  when  there  is 
advanced  cachexia  but  occasionally  they  occur  so  early  that  they  may 
constitute  the  first  sign  of  the  disease. 

Secondary  growths  in  the  liver  are  frequently  found  at  autopsy. 
Usually  they  are  widely  disseminated  and  rather  small  in  size,  ranging 
from  i  centimeter  to  3  or  4  centimeters.  Hitschmann's  case  presented 
a  liver  which  was  literally  riddled  with  the  metastatic  nodules.  Paviot 
observed  a  case  in  which  there  was  a  tumor  4  centimeters  in  diameter 
on  the  convex  surface  and  many  other  growths  in  the  depths  of  the 
organ.  Liver  metastases  do  not  usually  give  rise  to  symptoms. 
Krawer  and  Macaggi  described  an  increased  size  of  the  liver  in  their 
case,  yet  this  condition  is  not  always  noted.  A  secondary  tumor  the 
size  of  a  fetal  head  was  not  even  suspected  in  the  cas"e  of  Schmorl. 

Kidney  metastases  have  been  described  by  Nitzel,  Tibaldi,  Gott- 
schalk,  and  many  others.  These  growths  are  usually  small  and  give  no 
symptoms.  Thus,  the  well-observed  case  of  Davis  and  Harris  gave  no 
symptoms,  although  a  tumor  in  the  left  kidney  was  6  centimeters  in 
diameter.  The  urine  in  Gottschalk's  case  contained  characteristic 
plasmoidal  masses.  The  tumor,  however,  was  the  size  of  a  fetal  head. 
Secondary  growths  have  rarely  been  observed  in  the  ureter  (J. 
Schmidt),  in  the  bladder  (Jacubasch,  Krawer,  Perski,  Marchand), 
and  in  the  urethral  wall  (Holzapfel). 

Metastases  in  the  central  nervous  system  are  also  common.  They 
occur  most  often  in  the  occiptal  lobes  on  the  left  side.  They  may  be 
multiple,  yet  are  often  single  and  vary  in  size  from  a  minute  growth  to 
that  of  a  hen's  egg.  Metastases  in  the  brain  do  not  usually  have  the 
hemorrhagic  appearance  of  the  visceral  metastases.  Secondary 
growths  are  occasionally  noted  in  the  cord.  Kedrierski  and  others 
have  reported  cases. 

In  addition  to  these  sites,  metastases  have  been  found  in  the  most 
diverse  organs,  as  for  instance,  in  the  stomach,  large  and  small  intes- 
tines, heart,  pericardium,  pancreas,  spleen,  thyroid,  suprarenal  cap- 
sules, diaphragm,  bone  and  subcutaneous  tissue. 

Ovarian  Changes,  Associated  with  Chorioma. — The  ovarian 
changes  in  chorio-epithelioma  constitute  an  interesting  feature.  Wil- 


3i4  PELVIC   NEOPLASMS 

ton,  in  1840,  described  cystic  changes  in  the  ovaries  in  a  case  of  a  malig- 
nant mole;  since  then,  many  others  have  reported  similar  findings.  In 
1895,  Marchand  called  attention  to  the  frequency  of  ovarian  cysts  in 
chorio-epithelioma  cases.  Patellani,  in  1905,  found  that,  of  68  cases 
reported  upon  that  time,  62,  or  91  per  cent,  presented  bilateral  cystic 
changes.  Since  then,  it  has  been  seen  that  this  percentage  is  probably 
too  high  unless  one  includes  marked  grades  of  the  small  cystic  cavities 
seen  in  ovaries.  There  is  no  doubt,  however,  but  that  pronounced 
cystic  changes  in  both  ovaries  occur  so  frequently  with  chorio-epitheli- 
oma as  to  constitute  a  specific  anatomical  feature  of  the  disease.  It  is 
of  interest  that  in  several  cases,  the  cysts  receded  in  size  after  the  extir- 
pation of  the  tumor  or  mole,  although  they  persisted  in  the  cases  pro-  . 
gressing  to  death. 

The  cysts  may  be  very  numerous  and  small  or  present  as  multi- 
locular  changes  the  size  of  an  orange.  The  contents  are  thin,  yellowish, 
serous  fluid  containing  albumins,  lipoids,  and  a  little  mucin.  The  walls 
of  the  large  cysts  are  lined  by  a  deep  layer  of  large  over-nourished 
granular  polyhedral  cells,  resembling  exactly  the  lutein  cells  of  the 
early  corpus  luteum. 

The  origin  of  the  cysts  has  not  been  definitely  determined.  Jaffe 
and  Orthmann  feel  that  most  of  them  arise  by  distention  and  over- 
growth of  corpora  lutea.  The  small  multiple  cysts  of  gestation  are  not 
so  clearly  traced.  Seitz  thinks  that  they  arise  from  atresic  follicles  of 
the  ovary  which  begin  to  hypertrophy  in  the  sixth  week  of  pregnancy 
and  continue  to  term.  He  believes  that  these  follicles  have  no  relation 
to  the  corpora  lutea.  Stockel  finds  that  the  theca  cells  of  the  follicles 
may  wander  out  into  the  ovarian  stroma  during  pregnancy  and  form 
lutein  cell  groups  from  which  the  small  cysts  arise.  Schaller  and 
Pforinger  describe  such  cell  groups  in  their  case  which  were  so  abun- 
dant as  to  suggest  a  tumor  process.  The  majority  believe  that  the 
cysts  represent  a  disorder  of  lutein  secretion. 

L.  Frankel  advanced  the  view  that  the  disturbance  of  the  lutein 
function  induced  by  the  cyst  caused  the  death  of  the  ovum  and  the  pro- 
duction of  the  tumor  since  excision  of  the  corpus  luteum  prevented 
implantation  and  development  of  the  ovum.  The  latter  part  of  this 
theory  does  not  appear  substantiated.  L.  Pick  interpreted  a  cyst  as 
evidence  of  hypersecretion  leading  to  proliferation  of  the  chorion. 
Veit  considers  the  possibility  that  a  primary  ovarian  disease  yields  a 
diseased  ovum  which  degenerates  and  entails  abnormal  proliferation  in 
the  chorion.  Against  this  theory,  there  is  the  fact  that  chorio-epitheli- 
oma may  follow  a  normal  labor.  The  suggestions  that  the  cysts  result 
from  venous  congestion  (Seitz),  that  they  are  equally  characteristic  of 
normal  pregnancy  (Wallart),  and  that  they  belong  to  the  ordinary 
nutritional  changes  of  pregnancy  (Dungen),  also  are  disproved. 

Symptoms. — The  symptoms  may  be  divided  accordingly  as  they 


CHORIO-EPITHELIOMA  315 

arise  from  the  uterine  tumor  or  from  the  metastases.  The  latter  may 
be  subjective  or  objective. 

The  most  characteristic  and  prominent  symptom  of  the  primary 
uterine  tumor  is  hemorrhage.  This,  as  a  rule,  is  very  profuse  and  may 
even  be  alarming.  In  one  of  Vineberg's  cases,  the  second  hemorrhage 
was  so  great  that  it  would  have  caused  death  had  it  not  been  arrested 
by  packing.  Yet,  in  many  instances,  the  bleeding  may  be  comparatively 
slight,  although  protracted,  simulating  that  which  arises  from  retention 
of  membranes  or  placental  remnants.  In  very  rare  instances,  there 
may  be  no  bleeding,  even  though  the  growth  is  situated  at  the  placental 
site  as  in  the  case  of  Lichtenstein.  Amenorrhea  of  three  or  four 
months  duration  has  been  observed  in  a  few  cases  (Eden,  Caturani). 
This  singular  phenomenon  has  been  observed  only  in  cases  following 
hydatidiform  mole. 

Intraperitoneal  hemorrhage  has  been  responsible  for  the  initial  symptom 
in  cases  which,  in  their  growth,  perforated  the  uterus,  and  simulated  a 
ruptured  tubal  pregnancy.  Erck  and  Outerbridge  reported  such  a  case 
in  a  woman  of  twenty-seven  who  developed  these  symptoms  six 
months  after  an  incomplete  abortion  suggestive  of  hydatidiform  mole. 
They  collected  8  similar  cases  from  the  literature.  Hyde,  in  1915, 
reported  i  other. 

There  are  a  number  of  cases  in  the  literature  in  which  the  patients 
were  curetted  for  bleeding  of  rather  moderate  amount  but  the  symp- 
tom was  not  arrested  by  the  treatment.  In  quite  a  few  instances,  the 
patient  was  curetted  as  many  as  four  or  five  or  even  six  times  before 
the  condition  was  suspected.  Suspicion  of  the  presence  of  a  chorio- 
epithelioma  should  be  aroused  when  a  careful  curetting  shortly  after 
pregnancy  fails  to  arrest  bleeding. 

The  hemorrhage  soon  leads  to  anemia  with  its  train  of  symptoms. 
Cachexia  develops,  the  patient  feels  and  looks  ill,  and  the  septic  con- 
dition may  intervene.  The  latter  is  particularly  apt  to  occur  when  the 
case  has  been  curetted  several  times.  Occasionally,  there  is  complaint 
of  uterine  cramps  caused  by  the  expulsion  of  blood  clots  or  debris  of 
the  growth.  Pollosson  and  Violet  called  attention  to  this  symptom. 

Occasionally,  the  first  manifestations  of  the  disease  may  be  symp- 
toms from  metastases.  They  are  most  likely  to  present  in  cases  with 
involvement  of  the  lung.  A.  Straume  reports  such  a  case  which  was 
diagnosed  as  pulmonary  tuberculosis  on  account  of  hemoptysis, 
dyspnea,  and  pain  in  the  chest.  The  patient  had  had  no  uterine  bleed- 
ing, nor  had  she  given  a  history  of  recent  pregnancy.  The  initial  symp- 
toms are  rarely  due  to  cerebral  or  spinal  tumor.  A.  Kedrierski  reports 
a  case  in  which  paraplegia  was  the  initial  symptom,  developing  8 
months  after  a  pregnancy  at  term.  The  autopsy  disclosed  a  chorioma 
in  the  spinal  cord  at  the  level  of  the  fourth  lumbar  vertebra.  Other 
metastases  were  found  in  the  lungs  and  liver.  There  was  no  uterine 


316  PELVIC   NEOPLASMS 

tumor.  Although  metastases  in  the  kidney  have  frequently  been 
described,  symptoms  resulted  only  4n  the  case  of  Gottschalk  in  which 
the  urine  contained  characteristic  plasmoidal  masses.  The  tumor  in 
this  case,  however,  was  the  size  of  a  fetal  head.  The  involvement  of 
the  broad  ligament  is  frequently  attended  with  pain. 

Objective  symptoms  may  be  offered  by  the  presence  of  vaginal  or 
vulval  metastases.  They  appear  most  frequently  in  the  anterior  wall 
near  the  urethral  meatus.  They  vary  in  size  from  that  of  an  almond 
to  a  hen's  egg;  the  larger  growths  are  usually  single.  They  possess  a 
deep  bluish  color  and  appear  very  vascular. 

In  the  rapidly  growing,  highly  malignant  forms,  symptoms  of  intox- 
ication soon  appear  as  a  result  of  decomposition  of  the  tumor  masses, 
or  from  actual  infection.  A  foul  vaginal  discharge  is  noted,  there  is 
fever  of  irregular  course,  and  the  woman  rapidly  becomes  emaciated. 
Occasionally,  chills  and  high  fever  are  present,  which  are  due  not  so 
much  to  the  septic  process  as  to  extensive  metastases.  While  septic 
conditions  of  the  primary  tumor  are  not  uncommon,  pyemia  does  not 
develop,  nor  have  organisms  been  found  in  the  metastatic  tumors. 

Diagnosis. — The  diagnosis  of  chorio-epithelioma  is  often  attended 
with  difficulty.  The  condition  should  be  suspected  when  profuse 
hemorrhage  follows  a  hydatidiform  mole  that  had  been  thoroughly 
removed.  Vineberg  recommends  that,  when  removing  a  mole,  the 
uterine  wall  should  be  thoroughly  explored  with  the  finger  for  any 
suspicious  nodule  or  any  thin  area  of  the  wall.  The  diagnosis  may 
occasionally  be  made  in  this  manner  when  the  tumor  is  very  early. 
Vineberg  reports  two  such  cases  and  Eden  one.  The  cervix  is  usually 
patulous  when  the  growth  follows  shortly  after  labor  at  full  term  so 
that  it  is  possible  to  palpate  the  interior  of  the  uterus  with  the  ringer. 
The  presence  of  an  elevated,  fairly  hard  nodule  with  an  excavation  in 
the  center  is  almost  pathognomonic.  The  diagnosis  is  practically  abso- 
lute when  the  characteristic  reddish  blue  papules  appear  on  the  vagina 
or  in  the  vulva. 

The  greatest  difficulties  are  encountered  when  the  growth  follows 
an  early  miscarriage  because  in  such  cases  one  cannot  be  certain  that 
the  bleeding  did  not  follow  the  retention  of  placental  remnants  even 
though  the  case  had  been  treated  by  curettage.  One  must  then  turn 
to  the  microscope  to  complete  the  diagnosis,  although  the  evidence 
may  not  be  conclusive  and  may  even  be  misleading.  One  naturally 
hesitates  to  remove  the  uterus  of  a  young  woman  in  the  absence  of 
definite  clinical  evidence  and  in  the  presence  of  only  suspicious  material 
removed  by  the  curette.  Vineberg  recommends  that  both  the  interior 
and  exterior  of  the  uterus  be  palpated  and  inspected  in  such  cases, 
obtaining  exposure  by  inverting  a  part  of  the  uterus  after  a  vaginal 
hysterotomy  and  colpotomy. 

MICROSCOPIC  DIAGNOSIS. — The  microscopic  picture  of  the  tumor  in  the 


CHORIO-EPITHELIOMA  3 1 7 

uterus  is  perfectly  definite.  Yet  there  is  much  difficulty  in  diagnosing 
many  of  these  tumors  only  from  curettings.  The  presence  of  tropho- 
blastic  tissue  in  the  uterus  without  villi  three  or  four  weeks  after  a 
pregnancy  gives  a  positive  diagnosis.  When  villi  are  present,  the 
diagnosis  is  more  difficult,  yet  in  such  cases  one  should  not  forget  the 
possibility  that  there  is  a  malignant  mole.  No  precise  statement  can 
be  made  as  to  the  amount  and  character  of  epithelial  overgrowth  which 
will  warrant  a  diagnosis  of  malignancy.  There  is  normally  present  for 
some  weeks  after  a  pregnancy  a  certain  amount  of  infiltration  of  the 
endometrium  by  trophoblastic  elements.  Such  an  infiltration  is  more 
marked  after  a  hydatidiform  mole  in  which  there  is  also  evidence  of 
necrosis  of  maternal  tissues  and  infiltration  of  the  muscular  wall. 
Robert  Meyer  defines  the  position  of  the  microscope  in  curettings  as 
follows : 

"So  long  as  portions  of  the  placenta  are  present,  the  recognition  of 
hemorrhagic  and  necrotic  tissues,  leukocytic  infiltration  and  cells  of 
Langhans  within  the  mucous  membranes  is  insufficient  to  justify  the 
diagnosis  of  chorio-epithelioma,  since  these  also  form  a  part  of  the 
picture  of  placental  retention.  The  significance  of  the  same  discovery 
in  the  uterine  muscle  is  much  more  difficult  to  estimate.  Only  when 
one  can  be  quite  certain  that  all  villus  remnants  have  been  removed, 
is  it  possible  to  reckon  on  the  disappearance  of  the  chorionic  epithelial 
elements  in  the  muscle  in  from  two  to  three  weeks.  After  this  time, 
should  suspicious  materials  be  expelled,  or  should  a  new  curettage 
bring  to  light  fresh  masses  of  chorionic  epithelium,  then,  no  matter 
what  the  condition,  they  must  be  regarded  as  suspicious.  Before  this 
time,  the  recognition  of  large  epithelial  and  epitheloid  cells  of  varying 
form  with  large  or  grouped  nuclei,  and  multinucleated  giant  cells,  by  no 
means  justify  the  diagnosis  of  malignant  tumor,  even  when  they  appear 
in  long  processes  and  broad  masses  and  replace  and  break  through  the 
walls  of  vessels,  for  this  chorionic  invasion  can  occur  apart  from  malig- 
nant new  formation." 

While  much  doubt  must  attend  the  study  of  scrapings  shortly  after 
pregnancy,  there  can  be  no  question  of  the  meaning  of  the  character- 
istic cells  removed  by  scraping  the  interior  of  the  uterus  several 
months  or  years  after  the  pregnancy.  They  indicate  an  abnormal  con- 
dition and  should  be  treated  as  such. 

DIFFERENTIAL  DIAGNOSIS. — Cases  of  chorio-epithelioma  must  care- 
fully be  excluded  from  examples  of  septic  infection  in  the  presence  of 
retained  products  of  conception.  Sloughing  fibroids,  and,  rarely,  sar- 
coma or  carcinoma  of  the  uterus,  may  be  confused  with  late  chorio- 
epithelioma.  Usually,  slight  bleeding,  fever,  and  a  purulent  vaginal 
discharge  coming  on  shortly  after  the  interruption  of  pregnancy  and 


318  PELVIC   NEOPLASMS 

associated  with  an  enlarged  uterus  containing  masses  of  broken  down 
tissue  form  a  picture  suggestive  of  puerperal  infection.  Yet  if  the 
pregnancy  had  been  a  hydatidiform  mole,  the  case  should  be  regarded 
with  the  greatest  suspicion.  The  chorioma,  on  account  of  its  friability, 
can  be  readily  and  thoroughly  removed  by  a_curette,  leaving  the  uter- 
ine wall  smooth  and  uniform.  This  treatment  should  be  reserved  for 
the  most  suspicious  cases  for,  while  the  neoplasm  is  benefited  tem- 
porarily, the  condition  of  the  abortion  case  may  be  made  worse.  The 
hemorrhage  soon  recurs  and  the  uterine  cavity  again  becomes  filled 
with  large  quantities  of  soft  tissues  in  the  chorioma  cases.  The  rapid 
reformation  (in  two  to  four  weeks)  of  the  tissue  debris  is  characteristic 
of  the  disease  and,  in  the  opinion  of  Veit,  serves  to  distinguish  it  from 
the  septic  retained  products  of  conception. 

Prognosis. — Taken  as  a  whole,  the  chorio-epithelioma  group  are 
the  most  malignant  tumors  known.  Death  usually  takes  place  within 
a  year.  Yet  the  prognosis  is  complicated  by  the  fact  that  certain  cases 
have  recovered  spontaneously  or  after  simple  curettage  or  other  incom- 
plete operations,  even  in  the  presence  of  metastases.  Nor  is  it  possible 
to  classify  such  cases  according  to  their  histologic  picture. 

In  1904,  von  Velits  collected  8  cases  of  chorioma  in  which  curettage 
was  followed  by  recovery.  Ewing  states  that  5  of  them  were  composed 
chiefly  of  large  wandering  syncytial  cells  which  were  not  accompanied 
by  proliferating  masses  of  Langhans'  cells.  He,  therefore,  classified 
the  5  cases  as  syncytioma  or  syncytial  endometritis  for  which  Menge 
recommended  curettage  as  the  operation  of  choice.  Of  the  remaining 
cases,  according  to  Ewing's  analysis,  Risel's  and  Blumreich's  were 
hydatidiform  moles,  with  active  proliferation  of  cells,  probably  chorion- 
adenoma.  Graefe's  case  was  inadequately  described.  Yet  Geist,  in 
1921,  reported  a  case  of  typical  choriocarcinoma  which  made  a  perfect 
recovery  following  curettage  without  any  subsequent  treatment. 

In  a  number  of  cases,  Marchand,  Noble,  Kolomenkin,  Fleischmann, 
Hermann,  Dungen,  and  Cazin-Segoud,  the  patient  recovered  after 
operation,  although  the  tumor  was  incompletely  removed.  In  all  of 
these  instances,  the  proliferating  Langhans'  cells  were  missing  and  the 
tumors  consisted  chiefly  of  cyncytial  masses.  In  Dungen's  case,  there 
was  recovery  after  an  early  hysterectomy  for  chorioma,  and  shortly 
after  a  vaginal  tumor  developed  but  spontaneously  disappeared.  This 
case  is  similar  to  Schlagenhaufer's  and  suggests  the  possibility  that 
isolated  metastases  of  choriocarcinoma  may  spontaneously  disappear. 
In  Noble's  case,  the  size  of  the  tumor,  8  centimeters  by  8  centimeters 
by  7.5  centimeters,  indicated  that  it  did  not  belong  to  the  more  malig- 
nant group  of  chorioma,  a  suspicion  which  was  confirmed  by  the  fact 
that  Langhans'  cells  were  absent  from  the  tumor.  Hitschmann  and 
Cristofoletti  record  a  growth,  the  operation  for  which  was  abandoned 
because  of  the  extent  of  the  tumor,  which  involved  the  vagina  and 


CHORIO-EPITHELIOMA  319 

bladder  and  which  had  infiltrated  through  the  pelvis.  The  patient 
improved  rapidly  in  spite  of  an  incomplete  operation.  One  month 
later,  there  were  no  signs  of  the  tumor  of  the  uterus  and  the  pelvic 
structures  seemed  to  be  free.  The  patient  was  in  perfect  health  seven 
years  later. 

It  is  apparent  that  neither  pulmonary  nor  vaginal  metastases  carry 
a  necessarily  fatal  prognosis,  although  it  should  be  emphasized  that 
the  very  great  majority  of  cases  with  cough  and  hemoptysis  speedily 
succumb.  The  gravity  of  vaginal  metastases  is  considerably  less 
serious,  since  quite  harmless  growths  may  result  there  from  deported 
cells  and  villi.  Yet  these  cases  must  merely  be  regarded  as  exceptions 
to  the  rule  that  chorio-epithelioma  are  extremely  malignant  tumors. 

Von  Fleischmann,  in  1905,  collected  the  cases  of  Chrobak,  von 
Franque,  Zagerjanski-Kissel,  Ladinski,  Neumann,  Schauta,  and 
Pestalozzi,  all  of  which  recovered  after  probable  occurrence  of 
metastases  in  the  lungs.  The  evidence  of  pulmonary  metastases 
consisted  of  cough  and  hemoptysis,  and  there  was  no  reasonable  doubt 
but  that  cell  emboli  occurred  and  were  eventually  absorbed.  This  con- 
clusion has  been  rendered  more  acceptable  by  what  has  been  learned 
more  recently  concerning  the  nature  of  pulmonary  emboli  from  the 
normal  placenta  and  their  usual  fate.  It  is  possible  that  some  of  the 
emboli  consisted  only  of  fibrin,  yet  Risel,  Eden,  and  Lockyer,  have 
noted  healed  nodules  in  the  lungs  surrounded  by  others  which  were 
still  growing  in  cases  which  terminated  fatally.  Teacher  has  made  a 
similar  observation. 

There  are  a  larger  number  of  cases  in  which  recovery  has  resulted 
after  the  development  of  vaginal  metastases,  and  it  is  in  these  that 
there  is  a  conflict  of  opinion  as  to  the  value  of  histologic  examinations 
of  excised  tissue.  Schmauch  collected  13  cases  which  recovered  in 
spite  of  the  fact  that  vaginal  metastases  developed.  Neumann  and 
Kolomenkin  reported  2  others.  The  observation  of  Rockafellow  is 
most  remarkable.  In  some  of  the  cases,  the  uterus  and  vaginal  nodules 
were  removed  at  operation.  In  others,  only  the  uterus  was  removed, 
while  in  the  cases  of  Fleischmann,  Herrmann  and  Kolomenkin,  neither 
the  uterus  nor  vaginal  nodules  were  completely  removed.  In  Rocka- 
fellow's  case,  the  uterus  was  removed  but  large  growths  recurred  in 
the  labia  every  few  weeks.  Sometimes,  they  were  as  large  as  a  kidney, 
and,  when  excised,  they  returned  in  a  week  or  so.  After  four  opera- 
tions for  recurrences,  the  patient's  condition  became  so  poor  that  it  did 
not  seem  worth  while  to  again  attempt  removal.  To  every  one's  sur- 
prise, the  growths  began  to  shrink  spontaneously  .and  disappeared  in 
a  few  weeks,  leaving  only  a  hard  ridge  to  indicate  their  former  site. 
The  patient  began  to  improve  and  in  a  short  time  regained  good  health 
and  remained  so  while  she  was  under  observation,  which  was  more 
than  two  years. 


320  PELVIC   NEOPLASMS 

• 

Ewing  contends  that  a  study  of  the  case  reports  clearly  indicates 
that  the  cases  which  recovered  after  pulmonary  and  vaginal  metastases 
belong  to  his  group  of  chorio-adenoma,  or  syncytioma,  and  not  to  the 
choriocarcinoma,  and  that  histologic  examination  is  of  much  value  as  a 
guide  to  prognosis.  In  15  cases,  villi  were  present  in  9,  in  3  the  growth 
was  atypical,  while  in  2  the  description  was  indefinite.  He  admits 
that  Schlagenhaufer's  case  was  possibly  choriocarcinoma,  although  the 
syncytial  cells  were  very  abundant  and  extremely  vaculoated  as  in 
chorio-adenoma.  The  nodule  was  small,  and  the  uterus  was  normal. 
Yet  this  review  has  received  no  confirmation  from  the  works  of  others. 
Vineberg  does  not  accept  it,  nor  is  it  confirmed  by  the  work  of  Geist; 
moreover,  it  appears  that  in  Schmauch's  compilation,  there  were  many 
deaths  in  cases  in  which  syncytial  cells  were  the  predominating  feature 
in  the  lungs  and  vagina,  and  that  Langhans'  cell  masses  were  deficient 
or  absent.  There  were  also  several  chorio-adenoma  in  this  group.  Yet, 
according  to  Ewing,  one  must  be  impressed  by  the  fact  that  death  in 
these  cases  has  often  resulted  from  more  or  less  accidental  conditions, 
such  as  hemorrhage  and  infection,  rather  than  from  the  progressive 
growth  of  the  tumor. 

Geist,  whose  study  is  quoted,  believes,  moreover,  that  Ewing  is 
too  pessimistic  in  his  prognosis  for  the  cases  presenting  as  chorio- 
carcinoma. Geist's  series  included  14  cases,  10  of  which  were  chorio- 
carcinoma, of  which  only  3  died.  Moreover,  i  case  presenting  curet- 
tings  typical  of  choriocarcinoma  recovered  following  curetting  without 
other  operative  procedures. 

In  the  light  of  the  gloomy  prognosis  given  usually  to  chorio-epi- 
thelioma,  it  is  refreshing  also  to  turn  to  Vineberg's  most  remarkable 
series.  He  records  9  cases,  only  i  of  which  died,  a  patient  developing 
sepsis  following  curettage  and  packing.  Unfortunately,  he  does  not 
state  the  exact  microscopic  pathology.  He  does  say,  however,  that 
his  "unusually  excellent  results  cannot  well  be  explained  by  the  mere 
assumption  that  all  his  cases  were  of  a  semibenign  variety  as  that  would 
be  a  fortuitous  occurrence,  not  paralleled  by  a  series  of  a  similar  num- 
ber of  cases  in  the  literature."  He  feels  that  it  is  more  within  reason  to 
attribute  the  results  to  the  fact  that  the  diagnosis  was  made  at  an  early 
stage  of  the  disease  than  to  the  assumption  that  every  growth  was  of  a 
nonmalignant  type. 

Teacher  has  arranged  his  collected  series  of  188  cases  to  show  the 
relation  of  the  mortality  to  the  type  of  pregnancy  which  antedated  the 
tumor.  There  were  73  cases  which  followed  a  hydatidiform  mole  with  a 
mortality  of  53.4  .per  cent.  There  were  59  cases  which  followed  an 
abortion  with  a  mortality  of  66.1  per  cent.  Following  labor  at  term, 
there  were  49  cases,  with  a  mortality  of  79.6  per  cent.  Seven  ectopic 
choriomata  were  included  in  his  study,  only  i  of  which  recovered. 
Radical  operation  was  performed  only  99  times  with  36.4  per  cent  mor- 


CHORIO-EPITHELIOMA  321 

tality.  Recurrences  were  noted  within  six  months,  or  not  at  all,  except  in 
5  cases.  In  i  case  (Loblein),  recurrences  did  not  deevlop  for  one  year. 
The  high  mortality  in  the  cases  following  lab'or  at  term  is  very  striking. 

Treatment. — There  is  not  a  uniform  agreement  as  to  the  proper 
method  of  treatment  as  one  would  expect  at  first  sight,  of  a  tumor 
which  arises  from  the  uterus  and  which  is  usually  classed  as  the  most 
malignant  of  all  neoplasms.  Aside  from  the  fact  that  there  may  be 
considerable  difficulty  in  determining  the  diagnosis,  the  essentials  of 
treatment  may  be  confused  because  the  uterus  may  not  contain  a  tumor 
(the  disease  presenting  as  metastases)  and  because  many  cases  have 
been  cured  by  curetting  alone.  Although  there  are  many  who  argue 
for  minor  measures,  there  is  no  doubt  but  that  the  routine  performance 
of  a  hysterectomy,  together  with  the  removal  of  local  growths  will 
appeal  to  nearly  any  surgeon  as  a  rational  procedure.  Some,  as  Ewing, 
believe  that  conservative  treatment  is  indicated  in  the  presence  of  less 
advanced  growths  and  especially  in  young  women,  arguing  that  the 
first  treatment  should  consist  only  in  a  curettage  and  the  removal  of 
vaginal  metastases.  If  the  symptoms  recur,  hysterectomy  is  then 
indicated.  Justification  for  such  a  plan  of  treatment  cannot  be  obtained 
from  the  history  of  other  neoplasms.  It  has  resulted  because  in  the 
earlier  cases,  the  tumor  was  thought  to  metastasize  so  early  that  the 
removal  of  the  uterus  alone  would  not  improve  the  situation.  Active 
treatment,  in  consequence,  was  not  undertaken  after  the  diagnosis  had 
been  made  from  curettings.  Yet  the  study  of  fnany  such  cases  who, 
although  abandoned  to  their  fate,  presently  came  to  recovery,  showed 
that  the  tumor  was  not  invariably  fatal  and  that  recovery  might  follow 
from  distinctly  minor  measures.  A  policy  of  delay,  in  the  light  of 
Vineberg's  remarkable  results,  no  longer  seems  indicated. 

Schmauch  and  Ewing  are  in  accord  with  the  statement  that  opera- 
tion is  contra-indicated  and  merely  hastens  the  fatal  issue  when  metas- 
tases have  occurred.  On  the  contrary,  there  are  cases  in  the  literature 
which  have  recovered  after  incomplete  operation  even  when  the  find- 
ings indicated  that  the  tumor  was  really  choriocarcinoma.  Geist,  especially, 
states  that  a  diagnosis  of  choriocarcinoma,  even  with  metastases,  is  not 
necessarily  fatal.  There  is  so  much  chance  of  error  in  a  diagnosis 
from  scrapings  or  from  structures  removed  from  vaginal  metastases 
that  any  surgeon  should  feel  the  responsibility  of  refusing  hysterectomy. 

Repeated  curetting  seems  to  be  an  extremely  dangerous  procedure, 
since  it  is  prone  to  set  free  particles  of  growth  which  may  escape  into 
the  circulation  and  cause  metastases.  Hitschmann  and  Cristofoletti 
studied  300  cases  in  the  German  literature  and  made  a  comparison 
between  the  results  of  cases  that  were  curetted  and  those  that 
were  not  curetted.  The  metastases  were  much  more  extensive  and 
rapid  in  the  former  group.  They  also  found  that  the  cases  who  had 
died  without  operation  had,  as  a  rule,  fewer  metastases  than  those  who 


322  PELVIC  NEOPLASMS 

were  subjected  to  hysterectomy.  Especially  did  the  trauma  incidental 
to  vaginal  hysterectomy  cause  widespread  metastases. 

The  abdominal  panhysterectomy  is  the  method  of  choice,  because 
of  the  fact  that  it  necessitates  less  trauma  than  the  vaginal  operation. 
Hitschmann  and  Cristofoletti  advise  the  excision  of  the  deep  pelvic 
veins  which  are  frequently  filled  with  extensions  from  the  growth. 
Vineberg  does  not  agree,  stating  that  the  venous  extensions  frequently 
disappear  spontaneously.  We  advise  the  most  extensive  removal  that 
the  individual  case  will  stand. 

Radium. — Radium  has  not  been  tried  in  enough  cases  to  warrant 
conclusions  as  to  its  value.  There  is  no  doubt  that  there  may  be 
trauma  attending  its  insertion.  Ewing  calls  attention  to  the  danger 
of  hemorrhage  following  its  application.  In  Erck  and  Outerbridge's 
case,  it  was  employed  for  the  treatment  of  an  extensive  recurrence 
which  was  causing  alarming  hemorrhage  six  weeks  after  a  supravag- 
inal  hysterectomy.  At  time  of  operation,  the  case  presented  an  exten- 
sive chorio-epithelioma  which  had  penetrated  the  uterine  wall  and 
given  rise  to  a  severe  intra-abdominal  hemorrhage.  A  month  after  the 
radium  treatment,  the  patient  was  subjectively  well.  There  is  no  later 
report  of  the  case.  Clark,  in  1921,  reports  2  cases  treated  for  hemor- 
rhage which  are  still  alive  between  six  and  seven  years.  There  are 
also  a  few  cases  noted  in  the  German  literature.  We  have  tried  it  in 
one  case  unsuccessfully.  The  case  was  a  typical  chorio-epithelioma 
and  received  3,420  me.  hours  without  producing  marked  change. 

While  an  insufficient  number  of  cases  have  been  reported  to  enable 
one  to  speak  from  actual  results,  radium  from  the  theoretical  stand- 
point appears  as  the  logical  treatment  of  this  condition. 

LITERATURE 

CATURANI.    Am.  J.  Obst.     1917.     75:591. 

ERCK  AND  OUTERBRIDGE.    Internat.  Clin.    25th  Series,     i :  203. 

EWING.     Neoplastic  Diseases.     1919. 

FINDLEY.     J.  Am.  M.  Ass.     1904.    43:  1351. 

Am.  J.  Obst.     1917.     75:  968. 
v.  FLEISCHMANN.    Monatschr.  f.  Gynak.     1903. 
GEIST.     Surg.,  Gynec.  &  Obst.     1921.    32:  427. 
KYNOCH.    Edinb.  M.  J.     1919.    22:  226. 
MARCH  AND.     Ztschr.  f.  Geburtsh.     1898.    39:  173. 
MEYER.    Am.  J.  Obst.     1918.     78:64. 
POLLOSSON  AND  VIOLET.    Ann.  Gynec.     1913.     10:  2571. 
RIES.    Am.  J.  Obst.     1915.    72:  46. 
ROCKAFELLOW.     Iowa  S.  M.  J.     1915.    5:  428. 
SANGER.    Arch.  f.  Gynak.     1893.    44:  89. 
SCHMAUCH.    Surg.,  Gynec.  &  Obst.     1907.    5:259. 
TEACHER.    J.  Obst.  &  Gynec.  British  Empire.     1903.    4. 
VINEBERG.    Tr.  Am.  Gynec.  Soc.     1918.    43:  379. 


CHAPTER  XII 
TUMORS  OF  THE  OVARY 

Classification — Frequency — Nonproliferating  cysts — Follicle  cysts — Corpus  luteum  cysts — 
Blood  cysts  of  the  ovary — Retention  cysts  not  derived  from  the  follicle — Tubo- 
ovarian  cysts  —  Symptoms  —  Diagnosis  —  Treatment — Parenchymatogenous  tumors — 
Epithelial  tumors — Histogenesis — Pseudomucinous  cystadenoma — Microscopic  picture 
— Solid  adenoma — Serous  cystadenoma — Racemose  ovarian  cysts — Myxomatous  de-, 
generation  of  surface  papillae — Other  adenoma — Ovarian  carcinoma — Etiology — Age 
—  Classification  —  Solid  ovarian  carcinoma  —  Cystic  carcinoma  —  Adenocarcinoma 
pseudomucinum  —  Primary  squamous-cell  epithelioma  —  Atypical  forms  —  Clear-cell 
cancer  —  Carcinoma  resembling  lymphosarcoma  —  Krukenberg  tumors  —  Metastatic 
carcinoma — Clinical  features  of  ovarian  cancer — Stages  of  growth — Lymph  gland 
involvement — Involvement  of  neighboring  organs — Symptoms — Complications — Diag- 
nosis— Treatment — Prognosis — Embryoma — Etiology — Cystic  dermoids- — Frequency  — 
Age  —  Appearance  and  form  —  Structure  —  Atypical  forms  of  dermoids  —  Multiple 
dermoids  —  Malignant  degeneration  dermoids  —  Symptoms — Diagnosis — Treatment — 
Prognosis  —  Teratoma — Struma  ovarii — Symptoms — Diagnosis — Treatment— Progno- 
sis— Stromatogenous  tumors — Fibroma  and  myoma — Symptoms  —  Diagnosis  —  Prog- 
nosis— Treatment — Osteoma  and  chondroma — Myxoma — Angioma — Sarcoma — Adeno- 
myoma — Mesonephric  tumors — Malignant  tumors  of  corpus  luteum —General  symp- 
toms of  ovarian  tumors — Complications — Torsion — Causes — Symptoms. 

Because  the  ovary  contains  such  an  extraordinary  variety  of  ener- 
getic cellular  elements,  it  is  more  likely  to  be  the  seat  of  tumor  forma- 
tion than  any  other  structure  in  the  body.  Under  the  general  heading 
of  ovarian  tumors  are  included  not  only  the  true  neoplasms,  but  a 
group  of  tumors  which  are  usually  regarded  as  the  result  of  inflam- 
matory changes. 

Classification. — A  number  of  classifications  have  been  proposed, 
although  none  are  completely  satisfactory.  The  oldest  divided  the 
growths  into  cystic  and  solid  tumors  and  was  of  service  at  a  time  when 
the  operative  treatment  consisted  chiefly  in  tapping.  Later,  a  division 
into  benign  and  malignant  tumors  was  attempted.  Waldeyer  early 
sought  a  classification  according  to  the  histogenesis,  and  divided  them 
into  epithelial  and  connective  tissue  tumors.  Pfannenstiel  proposed 
an  elaborate  classification  which  at  least  forms  the  basis  for  the 
majority  of  recent  authors.  He  presented  the  subject  in  three  main 
divisions:  (i)  nonproliferating  cysts;  (2)  new  formations;  and  (3) 
mixed  tumors.  The  new  formations  were  divided  further  into  pa- 
renchymatogenous  and  Stromatogenous  tumors.  The  details  of  the 
classification  are  as  follows  : 

323 


324  PELVIC   NEOPLASMS 

I.  Nonprolif crating  cysts 

(Follicular  cysts;  cysts  of  the  corpus  luteum) 

II.  New  formations 

A.  Parenchymatogenous  tumors 

(Tumors  arising  from  germinal  or  follicular  epithelium,  or  from  the  ovum) 

1.  Epithelial  new  formations 

a.  Cystoma  serosum  simplex 

(Simple  cyst) 

•  Pseudomucinosum 
(Multilocular  cysts) 

b.  Cystadenoma 

Serosum 

(Papillary  cysts) 

c.  Carcinoma 

2.  Embryomata 

(Tumors  springing  from  the  ovum) 

a.  Dermoid  cysts 

b.  Teratomata 

B.  Stromatogenous  tumors 

(Tumors  arising  from  the  connective  tissue) 

1.  Fibroma 

2.  Sarcoma 

3.  Perithelioma  and  Endothelioma 

III.  Mixed  tumors 

(Various  combinations  of  the  tumor  processes  enumerated) 

This  classification  will  be  followed  in  the  main,  with  a  few  unim- 
portant changes. 

Frequency. — Ovarian  tumors  were  found  in  1.4  per  cent  of  36,158 
cases  in  Martin's  clinic.  Stander  found  the  relative  frequency  of  a 
series  of  295  cases  as  follows: 


Tumor  Cases  Per  cent 


Cystadenoma  

20=; 

60.  S 

Carcinoma  

AO 

13.6 

Embryoma       

26 

8.8 

Sarcoma  

20 

6.8 

Fibroma  

4 

i  .4 

NONPROLIFERATING  CYSTS 

The  tumors  of  this  group  are  thought  to  be  retention  cysts  result- 
ing because  of  errors  in  the  development  or  retrogression  of  graafian 
follicles.  There  are  two  chief  types:  (i)  follicle  cysts,  which  are  sup- 
posed to  be  caused  by  abnormal  secretion  of  atresic  follicles;  and  (2) 
corpus  luteum  cysts,  which  result  from  incomplete  involution  of  the 
corpus  luteum..  They  are  not  classed  as  true  neoplasms.  In  addition 
to  these,  there  are  a  number  of  cysts  which  arise  as  results  of  inflam- 
matory changes. 


TUMORS    OF    THE    OVARY  325 

Follicle  Cysts. — There  are  two  forms:  (i)  the  small  cystic  degen- 
eration in  which  the  whole  cortex  of  the  ovary  is  converted  into  a  mass 
of  small  cysts;  and  (2)  the  simple  follicle  cysts,  or  hydrops  folliculi. 

SMALL  CYSTIC  DEGENERATION  OF  THE  OVARY. — Under  this  heading, 
we  will  consider  the  type  which  occurs  independent  of  inflammatory 
exudate.  It  is  seen  often  in  women  with  the  pubescent  type  of  uterus, 
frequently  in  cases  with  enlarged  retroflexed  or  retroverted  uteri,  and 
extremely  often  when  there  are  varicose  veins  of  the  broad  ligament. 
It  is  believed  to  result  from  some  chronic  circulatory  condition  which 
causes  a  thickening  or  fibrosis  of  the  stroma  of  the  ovarian  cortex 
which  prevents  rupture  of  the  enlarging  follicles.  It  may  result  from 
mild  ascending  infections  of  the  genital  tract  which  do  not  progress 
far  enough  to  cause  adhesions,  but  which  occasion  disturbances  of  the 
pelvic  circulation.  All  do  not  agree  that  it  is  essentially  an  abnormal 
process.  Nagel,  and  others,  have  urged  that  it  represents  only  minor 
departures  from  the  normal  follicle.  In  proof  of  this,  they  state  that 
it  is  occasionally  seen  in  infants  who  present  no  pelvic  pathology. 
At  any  rate,  the  meaning  of  the  phenomenon  is  not  clear.  The  picture 
seen  in  a  single  cyst  bears  a  close  resemblance  to  an  atresic  follicle. 
Yet,  instead  of  seeing  one  or  two  enlarged  follicles  as  in  the  latter  con- 
dition, the  whole  ovary  of  the  small  cystic  type  presents  as  a  cystic 
mass  between  the  spaces  of  which  there  is  an  extremely  dense  stroma. 

The  disease  is  usually  bilateral.  The  ovary  may  be  somewhat 
enlarged,  although  this  is  not  invariable.  The  tunica  albuginea  is 
dense  and  thickened,  except  where  the  small  cysts  bulge  through. 
Small  growing  follicles  may  be  found  in  the  stroma  between  the  cysts, 
although  they  are  few.  The  hilum  contains  obliterated  blood  vessels 
in  which  there  are  hyaline  changes.  The  cysts  usually  form  projec- 
tions on  the  surface  which  may  be  seen  or  felt,  but  the  enlargement 
may  lie  entirely  within  the  substance  of  the  ovary.  The  cysts  are 
usually  less  than  I  and  are  rarely  more  than  2  centimeters  in  size. 
They  contain  clear  fluid.  They  may  so  press  upon  each  other  as  to 
cause  various  irregular  shapes  which  vary  greatly  from  the  normal 
rounded  outline.  The  partition  between  two  cysts  may  become  so 
thin  that  a  communication  between  them  is  eventually  established. 
The  cyst  wall  is  lined  with  a  single  layer  of  low  cubic,  or  somewhat 
flattened  epithelium,  which,  in  some  places,  may  be  absent  or  trans- 
formed into  granular,  fatty,  or  hyaline  areas.  The  ovum  and  discus 
proligerus  have  disappeared.  Degenerated  epithelium,  fat  drops,  blood 
corpuscles,  and  crystals  of  cholesterin  may  occasionally  be  found  in 
the  cyst.  The  ovarian  stroma  is  usually  very  dense. 

SIMPLE  FOLLICLE  CYSTS. — This  condition  is  also  known  as  hydrops 
folliculi.  The  cysts  are  usually  single,  and  rarely  more  than  two  or 
three  are  present.  They  vary  in  size  from  I  or  2  centimeters  to  10 
or  12  centimeters.  The  majority  are  from  3  to  5  centimeters  in  diam- 


326  PELVIC  NEOPLASMS 

eter.  The  cysts  are  smooth  and  globular,  with  thin  transparent  walls, 
and  clear  serous  contents.  Rarely,  they  contain  turbid  or  brown  fluid 
as  a  result  of  degeneration  or  hemorrhage.  They  are  usually  situated 
at  one  pole  of  the  ovary,  although  the  larger  cysts  may  occupy  nearly 
the  entire  organ.  The  surface  of  the  ovary  not  presenting  as  a  cyst 
is  usually  wrinkled  and  exhibits  a  thickened  tunica.  The  ovarian 
stroma  may  be  little  altered.  The  cyst  wall  is  lined  by  a  layer  of 
flattened  epithelium,  surmounting  a  connective  tissue  which  is  poor 
in  cells.  Isolated  areas  of  degeneration  may  be  seen  in  the  epithelial 
lining.  Follicle  cysts  occasionally  present  small  papillary  outgrowths, 
extending  into  the  cavity.  They  appear  as  wartlike  excrescences 
which  are  regarded  as  local  hyperplasia  of  the  connective  tissue,  rather 
than  as  an  outgrowth  of  epithelium. 

The  tumors  are  essentially  benign  and  are  believed  to  develop  from 
atresic  follicles.  The  secretion  develops  at  first  from  the  lining  epithe- 
lium, and  later  the  mass  grows  in  size  from  transudates  from  the  blood 
vessels  of  the  internal  theca  layers. 

Corpus  Luteurn  Cysts. — These  cysts  are  nearly  always  single  and 
unilocular,  although  sometimes  two  may  be  present.  They  grow 
slowly  and  seldom  are  larger  than  2  or  3  centimeters  in  diameter, 
although  they  may  attain  the  size  of  a  child's  head.  Their  true  condi- 
tion was  first  recognized  by  Rokitansky.  They  develop  usually  from 
mature  follicles  which  do  not  expel  their  contents,  but  in  which  hemor- 
rhage takes  place  and  involution  does  not  progress  normally.  They 
differ  from  follicle  cysts  chiefly  in  that  the  cystic  development  occurs 
in  the  more  advanced  stages  of  the  follicle,  and  that  there  is  a  lining 
of  lutein  cells. 

The  tumor  is  usually  found  at  the  pole  of  a  wrinkled,  crenated  ovary 
with  a  thickened  tunica.  It  presents  as  a  thick-walled  dark-colored 
cyst.  Infrequently,  it  is  clear.  The  cyst  wall  is  composed  of  two 
layers.  The  tumor  layer  is  usually  thrown  into  folds.  It  is  yellow 
or  orange-brown  in  color,  and  is  composed  of  lutein  cells.  The  outer 
layer  is  connective  tissue  derived  from  the  tunica  fibrosa.  The  lutein 
layer  varies  much  in  appearance,  suggesting  that  the  cyst  may  have 
different  modes  of  origin.  Usually,  it  presents  the  characteristic  struc- 
ture of  the  corpus  luteum  and  consists  of  large  epithelioid  cells  in  a 
delicate,  vascular  connective  tissue  stroma.  Occasionally  there  are 
no  epithelioid  cells  and  the  layer  consists  only  of  connective  tissue. 
The  epithelial  lining  varies  considerably.  As  a  rule,  it  is  composed 
of  a  single  layer  of  low  cubic  or  columnar  cells  lying  directly  upon  the 
lutein  cells.  Sometimes  there  are  several  layers  arranged  like  squa- 
mous  epithelium.  They  may  lie  directly  upon  a  hyaline  connective 
tissue. 

The  cysts  may  contain  clear  serous  fluid,  though  it  may  be  turbid 
and  dark  from  extravasation  of  blood.  Calcification  of  the  lutein 


TUMORS    OF    THE    OVARY  327 

hematoma  results  in  the  formation  of  the  so-called  "ovarian  stone," 
which  consists  of  a  hard,  calcareous  shell,  in  the  center  of  which  is  a 
shrunken  blood  clot. 

Lockyer  has  called  attention  to  displaced  lutein  cells  occurring  in 
masses  or  separate  from  one  another  in  the  ovarian  stroma.  Small 
cysts  may  develop  from  these  which  appear  practically  identical  with 
the  corpus  luteum  cyst.  These  cell  remnants  are  usually  described  as 
the  so-called  interstitial  gland. 

Bilateral  multilocular  lutein  cysts  often  occur  with  hydatidiform 
mole  and  chorio-epithelioma.  When  they  occur  with  the  former  con- 
dition, they  return  to  normal  after  the  uterus  is  freed  from  the  mole. 
Some  authors  classify  this  type  of  lutein  cyst  separately. 

Blood  Cysts  of  the  Ovary. — These  tumors  are  merely  the  result 
of  hemorrhage  into  follicle  or  corpus  luteum  cysts.  Therefore,  they 
are  not  pathological  entities.  The  hemorrhage  may  come  from  ex- 
travasation by  capillary  hemorrhage  or  by  a  larger  outpouring  of 
blood  at  the  time  of  menstruation.  Repeated  hemorrhages  at  consec- 
utive menstruations  may  cause  blood  cysts  of  considerable  size.  Von 
Franque  states  that  there  is  an  unusual  frangibility  of  the  blood  vessels 
in  chronic  ovaritis.  Usually  the  blood  is  gradually  absorbed  so  that 
the  cysts  do  not  long  remain  of  much  size.  Blood  cysts  undoubtedly 
form  a  considerable  proportion  of  the  puzzling  cases  in  which  an 
ovarian  cyst  has  been  found  to  disappear  completely  in  a  relatively 
short  space  of  time. 

Retention  Cysts  not  Derived  from  the  Follicle. — All  the  small  mul- 
tiple cysts  of  the  ovary  are  not  of  follicular  origin.  Rarely  one  may 
find  small  translucent  multiple  cysts  upon  the  surface  of  the  ovary, 
tubes  and  their  ligaments  lined  by  flat,  ciliated,  or  goblet  cells.  They 
are  usually  regarded  as  peritoneal  inclusions,  yet  Walthard  believes 
that  they  arise  from  undifferentiated  germinal  epithelium.  Babo  and 
von  Franque  suggest  that  they  arise  from  remnants  of  the  primitive 
nephros.  Pick  thinks  they  may  develop  into  cystadenoma. 

Tubo-ovarian  Cysts. — The  simple  ovarian  cysts  may  communicate 
with  the  fusiform  dilatation  of  the  tube,  forming  a  composite  cyst  of 
tube  and  ovary  which  resembles  a  glass  retort  in  form.  They  result 
from  the  union  of  an  ovarian  cyst  with  the  lumen  of  a  tube  which  has 
become  adherent  to  the  cyst  wall.  Thus,  an  ovarian  cyst  or  abscess 
may  rupture  into  an  adherent  tube  while  the  latter  is  either  normal 
or  distended;  or  a  hydrosalpinx  or  pyosalpinx,  when  adherent,  may 
burst  into  a  cyst  of  the  ovary.  The  communication  between  the  two 
cysts  varies;  usually  definite  and  circular,  it  may  appear  as  a  thin 
valvelike  partition.  Papillomatous  cysts  of  the  ovary  may  break 
through  into  a  distended  tube  as  may  carcinoma  of  the  ovary. 

Tubo-ovarian  cysts  may  be  unilateral,  or  bilateral.  Their  size  varies 
from  a  few  centimeters  to  7  or  8  centimeters  in  diameter.  They  are 


328  PELVIC  NEOPLASMS 

usually  unilocular.  They  are  lined  in  the  ovarian  compartment  by 
flat  cells,  and  in  the  tubal  section,  by  cylindrical  epithelium.  When 
corpus  luteum  cysts  fuse  with  the  tube,  they  may  be  recognized  by 
the  presence  of  lutein  cells  in  the  ovarian  compartment.  The  ovarian 
wall  of  the  cyst  is  thin  and  fibrous,  while  the  iubal  wall  contains  smooth 
muscle.  The  cyst  fluid  is  usually  clear  but  may  be  mucoserous,  turbid, 
orange  or  dark  colored. 

Symptoms  of  Nonproliferating  Cysts. — The  symptoms  may  vary 
slightly  with  tumors  of  the  different  groups,  yet  pain  or  discomfort 
constitute  the  chief  complaints.  There  may  be  sharp  pains  a  week 
or  two  before  the  period,  at  the  time  when  the  follicle  should  rupture. 
Dysmenorrhea  is  common.  The  pain  may  radiate  down  the  thighs. 
or  into  the  back.  Overexertion  is  often  followed  by  pains.  Occasion- 
ally there  may  be  only  pelvic  discomfort  often  accompanied  by  various 
reflex  manifestations,  such  as  occipital  headaches,  nervousness,  diges- 
tive upsets,  and  irritability.  Menorrhagia  is  common.  Metrorrhagia 
and  scanty  menstruation  may  result  from  marked  destruction  of  ova- 
rian tissue.  A  large  proportion  of  women  with  small  cystic  ovarian 
degeneration  are  sterile. 

Pain  results  when  there  is  extravasation  of  blood  into  the  cyst  or 
ovarian  structure.  It  is  referred  to  the  ovary  and  may  be  followed  by 
symptoms  of  the  acute  abdomen.  It  invariably  attends  torsion  of  the 
pedicle,  although  the  severity  of  the  pain  varies,  depending  on  the 
amount  of  torsion  and  the  suddenness  with  which  it  occurs.  It  often 
occasions  symptoms  which  when  on  the  right  side,  are  likely  to  be 
mistaken  for  appendicitis. 

The  reflex  symptoms  are  probably  caused  by  altered  ovarian  secre- 
tion. They  may  result  from  increased  tension  within  the  cyst. 

Diagnosis. — The  diagnosis  is  settled  by  presence  of  the  tumor. 
Often  it  cannot  be  made  with  certainty,  since  the  most  careful  exami- 
nation may  fail  to  reveal  a  cyst  of  small  size  which  has  arisen  into  the 
abdomen  if  the  patient  has  firm  abdominal  muscles  and  cannot  relax 
well.  As  a  rule,  the  cystic  tumor  may  be  felt  by  rectal  abdominal 
examination,  confirmed' by  the  vaginalabdominal  bimanual.  The  tumor 
is  cystic,  and  pressure  upon  it  usually  causes  pain.  It  does  not  move 
immediately  when  the  uterus  is  pushed  about.  It  is  not  firmly  adher- 
ent to  the  uterus,  nor  can  another  ovary  be  felt  upon  the  same  side. 
Irregularities  caused  by  enlarged  follicles  may  often  be  felt  through 
the  rectum.  The  sclerotic  ovaries  give  a  characteristic  feel.  The  im- 
portance of  rectal  examinations  cannot  be  overemphasized.  Occa- 
sionally it  is  difficult  to  make  a  diagnosis  even  under  an  anesthetic  as 
the  cyst  may  not  be  under  great  tension.  Broad  ligament  cysts,  or 
fibroids,  unruptured  ectopic  pregnancies,  a  thickened  tube  buried  in 
adhesions,  and  a  chronic  appendix  must  be  excluded  in  the  differential 
diagnosis. 


TUMORS    OF    THE    OVARY  329 

Treatment. — Definite  cysts  should  be  treated  surgically.  The  indi- 
cations for  operation  in  cases  of  small  cystic  degeneration  are  less  clear. 
It  is  not  wise  to  resort  to  surgery  unless  general  and  local  measures 
are  exhausted. 

The  general  treatment  consists  chiefly  in  hygiene.  The  appetite 
should  be  stimulated  and  especial  attention  paid  to  the  bowels.  The 
patient  should  be  encouraged  to  avoid  heavy  work  of  any  kind  or  any- 
thing which  will  induce  fatigue.  She  should  be  urged  to  live  as  much 
as  possible  in  the  open  air  and  choose  a  diet  of  simple  and  coarse  foods. 
Ovarian  extracts  usually  aggravate  the  condition  and  cause  hemor- 
rhage. 

Locally,  counter-irritation  occasionally  helps  a  good  deal.  Painting 
the  vaginal  vault  with  half  tincture  of  iodin  every  other  day  for  two 
weeks  between  the  periods  may  give  relief.  Pain  is  often  relieved  by 
vaginal  tampons,  soaked  in  a  solution  of  ichthyol  and  glycerin  in  the 
proportion  of  one  to  ten  or  one  to  fifteen,  inserted  every  third  day. 
Hot  vaginal  douches  of  soda  or  weak  lysol  solutions  should  be  given 
on  the  other  days.  The  above  outline  assumes  that  the  pelvis  other- 
wise presents  normally. 

Surgical  intervention  may  be  warranted  in  small  cystic  ovarian  de- 
generation which  has  been  treated  faithfully  by  long-continued  general 
and  local  treatment  without  relief,  provided  only  that  the  surgeon  is 
well  acquainted  with  the  necessary  refinements  of  pelvic  surgery,  since 
a  large  proportion  of  cases  are  made  worse  by  ordinary  surgical  treat- 
ment. 'A  surgeon  can  see  few  more  distressing  conditions  than  those 
caused  by  abdominal  and  pelvic  adhesions. 

Various  operative  measures  have  been  proposed  for  the  treatment 
of  retention  cysts.  The  following  have  been  described. 

PUNCTURE  OF  RETENTION  CYSTS. — Cysts  are  frequently  punctured 
with  a  needle,  knife  or  cautery  point.  It  does  not  seem  a  reasonable 
procedure  because  the  cyst  lining  can  rarely  be  destroyed  and  there  i's 
every  evidence  that  the  opening  will  be  closed  by  adhesions  and  that 
the  cyst  will  soon  refill.  Some  have  advised  burning  out  the  cyst  with 
the  actual  cautery  point.  Theoretically,  this  should  be  followed  by 
fibrosis,  although  it  is  a  question  how  the  ovarian  tissue  takes  care 
of  the  burn.  We  do  not  recommend  either  operation. 

RESECTION  OF  THE  OVARY. — While  theoretically  ideal,  this  operation  is 
not  followed  by  good  results  in  the  great  majority  of  cases.  We  have  had 
occasion  to  reoperate  a  large  number  of  cases  that  had  been  treated  in 
this  manner  by  others.  We  have  never  seen  a  case  in  which  the  stump 
was  not  covered  by  firm,  dense  adhesions.  While  no  one  who  is  not 
present  at  an  operation  can  pass  judgment  on  the  surgical  result,  since 
he  is  not  aware  of  the  primary  condition,  it  seems  reasonable  to  believe 
that  many  adhesions  occur  because  of  trauma  during  the  operation,  and 
from  the  subsequent  irritation  both  of  the  delicate  ovarian  tissue  and 


330  PELVIC   NEOPLASMS 

the  peritoneum  of  the  intestines  by  the  rough  knots  of  catgut  used  foi 
the  sutures. 

If,  when  the  abdomen  is  opened,  the  surgeon  is  convinced  that  a  resec- 
tion of  the  ovary  promises  the  best  results,  it  should  be  done  in  the  follow- 
ing manner:  The  ovary  is  held  by  the  gloved  hand  of  the  assistant  while 
the  operator  removes  a  wedge-shaped  piece  containing  the  diseased  portions 
with  a  very  sharp  knife.  Closure  is  effected  with  a  No.  oo  plain  catgut 
suture,  threaded  on  the  finest  curved  needle  that  it  is  possible  to  use.  Raw 
surfaces  should  be  turned  in  and  the  cover  made  so  that  only  one  knot  is 
exposed  at  the  end  of  the  operation.  The  procedure  is  technically  difficult, 
because  ovarian  tissue  is  friable  and  does  not  hold  a  suture  exerting  much 
tension.  Moreover,  it  is  often  impossible  with  the  naked  eye  to  determine 
accurately  the  line  of  demarcation  between  healthy  and  diseased  ovarian 
tissues.  Occasionally,  a  surgeon  resects  a  tumor  which  is  cancerous.  We 
have  seen  a  number  of  such  cases  subequently.  The  need  of  immediate 
laboratory  examination  of  all  resected  tissues  is  apparent. 

Personally,  we  do  not  recommend  the  operation  and  rarely  employ 
it,  feeling  that  the  majority  of  cases  are  made  worse  as  a  result  of  the 
procedure.  In  our  judgment,  it  is  justifiable  only  in  young  women,  whose 
other  ovary  has  been  removed,  and  who  are  anxious  for  children. 

REMOVAL  OF  THE  OVARY. — It  is  not  often  possible  to  remove  the  ovary 
alone  without  leaving  raw  surfaces  which  may  invite  adhesions.  When  the 
ovarian  ligament  is  long,  the  tumor  may  be  cut  away  so  that  the  stump 
of  the  ligament  may  be  turned  under  in  a  smooth  manner,  yet  this  is  not 
possible  without  often  causing  kinks  in  the  tube.  The  great  majority  of  cases 
will  be  treated  far  more  safely  by  removing  the  adnexa  of  the  affected  side. 

REMOVAL  OF  OVARY  AND  TUBE. — This  is  the  logical  treatment  for 
growths  demanding  surgical  intervention,  since  it  removes  the  affected 
tissue  and  permits  a  smooth  cover  of  the  raw  surfaces.  The  infundi- 
bulopelvic  ligament  is  ligated  with  No.  2  plain  catgut,  tied  firmly  with 
fhree  knots.  The  mesosalpinx  and  meso-ovarium  are  compressed  with 
clamps  and  the  tube  and  ovary  are  cut  away.  The  tube  is  removed 
from  the  uterine  cornua  by  a  wedge-shaped  incision.  The  wound  thus 
created  is  closed  with  plain  catgut  in  running  suture  as  far  as  the 
vessels  in  the  angle  of  the  uterus  and  broad  ligament.  These  are 
separately  tied.  The  round  ligament  is  now  used  to  effect  a  cover.  It 
is  tied  to  the  middle  portion  of  the  posterior  lateral  surface  of  the 
uterus  with  linen  or  silk  sutures,  after  which  the  stumps  of  the  ovarian 
vessels,  raw  surfaces  of  the  broad  ligaments,  and  free  edges  of  the 
round  ligament  are  turned  in  with  a  continuous  No.  oo  plain  catgut 
suture.  If  the  round  ligament  is  fastened  without  tension,  the  normal 
position  of  the  uterus  wrill  not  be  disturbed.  In  case  the  uterus  sags, 
or  is  posteriorly  displaced,  or  there  are  varicosities  of  the  pelvic  veins, 
this  Webster  cover  should  be  supplemented  by  a  suspension  on  the 
opposite  side. 


TUMORS    OF    THE    OVARY  331 


NEW  FORMATIONS 

New  growths  of  the  ovary  may  arise  either  from  epithelial  or  con- 
nective tissue  elements,  that  is,  parenchymatogenous  and  stromato- 
genous  tumors.  The  former  are  far  more  common.  The  tumors  may 
be  solid  or  cystic,  benign  or  malignant. 


PARENCHYMATOGENOUS  TUMORS 

Epithelial  Tumors. — These  growths  may  be  divided  into  two  main 
groups,  according  to  the  character  and  methods  of  growth  of  the  cells : 
(i)  benign  tumors,  or  cystadenomata ;  and  (2)  malignant  tumors,  or 
carcinomata. 

Cystadenomata. — Cystadenomata  of  the  ovary  comprise  the  group 
of  benign  tumors  which  exhibit  a  glandular,  or  adenomatous  character. 
They  are  said  to  form  between  70  per  cent  and  80  per  cent  of  all  ovarian 
tumors.  All  cystadenomata  are  essentially  multilocular  and  are  com- 
posed of  many  cystic  chambers  which  result  from  proliferation  of  the 
epithelial  cells  that  line  the  original  cyst.  These  hypertrophy  to  form 
daughter  cysts  which  in  turn  reproduce  themselves,  or  else  form 
papillary  masses  which  grow  into  the  cyst  cavities.  Often  some  cysts 
grow  at  the  expense  of  others,  which  they  compress  into  the  lateral 
wall  or  else  they  break  through  into  neighboring  cysts,  and  give  the 
appearance  of  a  unilocular  cyst.  Careful  examination,  however,  reveals 
the  true  character. 

Cystadenomata  may  be  variously  divtded.  Abel  grouped  them  into 
simple  cystadenomata  or  papillary  cystadenomata,  according  as  they 
formed  simple  cysts,  or  those  with  intracystic  and  superficial  papillary 
processes.  Gebhard  recognized  the  similarity  between  the  morphol- 
ogy of  ovarian  adenomata  and  uterine  carcinomata,  and  divided  them 
into  cystadenomata  evertens  and  invertens.  Pfannenstiel,  finding  a 
marked  difference  in  the  character  of  the  cell  secretion,  effected  a 
classification  upon  that  basis.  He  divided  them  into  pseudomucinous 
and  serous  cysts.  In  the  former  group  are  included  nearly  all  the 
simple  cystadenomata  while  the  latter  group  corresponds,  with  few 
exceptions,  to  the  papillary  cyst.  There  are  exceptions,  however,  since 
there  may  be  papillary  pseudomucinous  cystadenomata  and  serous 
cystadenomata  without  papillary  processes. 

HISTOGENESIS. — The  histogenesis  of  all  the  epithelial  new  formations 
of  the  ovary  has  been  much  disputed.  Indeed,  as  Goodall  states,  the 
more  one  delves  into  the  subject,  the  more  one  is  confused  by  the 
multiplicity  of  views  and  the  number  of  structures  from  which  ovarian 
tumors  may  arise.  All  the  various  epithelial  structures  which  occur 


332 


PELVIC   NEOPLASMS 


in  or  near  the  ovaries  have  been  accredited  with  their  origin.  Thus, 
the  tumors  have  been  said  to  arise  from  remnants  of  mullerian  and 
wolffian  tissues,  the  germinal  epithelium  and  its  derivatives,  the  medul- 
lary cord,  rete  ovarii,  the  follicular  epithelium,  the  ova,  corpora  lutea, 
atresic  corpora  and  the  interstitial  cells. 

The  theories  of  the  origin  of  cystadenomata  center  chiefly  around 
wolffian  remnants  and  germinal  epithelium.  They  are  of  interest  not 
only  to  explain  the  cystadenoma  but  also  to  account  for  the  carcinoma 
which  may  arise  from  them. 

Olshausen,  in  1877,  and  subsequently  Fischel,  Coblentz,  Doran, 
Howell,  and  Papov  advocated  the  theory  that  many  of  the  epithelial 
tumors,  especially  the  papillary  cysts,  arose  from  remnants  of  the 
wolffian  body.  The  theory  seemed  indicated  because  the  great 
majority  of  these  growths  developed  in  the  intraligamentous  portion 
of  the  ovaries,  and  the  cysts  and  papillae  were  lined  by  cylindrical 
ciliated  epithelium.  Indeed,  some,  as  Papov,  thought  they  were  able 
to  trace  the  development  of  wolffian  tubules  into  cystic  cavities  which 
contained  papillae.  Marchand,  in  1878,  gave  the  first  real  blow  to  the 
theory  when  he  described  an  ovary,  the  cortex  of  which  was  filled  with 
minute  cysts  containing  papillae  and  lined  by  ciliated  epithelium.  Since 
it  was  agreed  that  wolffian  body  rests  were  never  found  in  the  ovarian 
cortex,  he  was  forced  to  seek  other  origins  for  the  ciliated  cells.  He 
advanced  the  view  that  the  tumors  might  be  derived  from  the  ciliated 
epithelium  of  the  fimbria  of  the  tube  which  had  extended  over  the 
lateral  portion  of  the  ovary  and  had  given  off  tubules  of  ciliated  epithe- 
lium, like  Pfliiger's  ducts  into  the  ovarian  stroma.  From  these  arose 
cysts  lined  by  ciliated  epithelium.  Later  Massabuau  and  Etienne  were 
unable  to  confirm  the  observation  of  Papov.  Walthard  was  able  to 
find  only  one  case  of  an  edematous  structure  in  the  wolffian  rests  in 
the  examination  of  many  ovaries  cut  in  serial  sections.  Moreover, 
De  Sinety  and  Mallasez,  and  later  Flaischen,  were  able  to  trace  the 
continuity  of  the  germinal  epithelial  of  the  surface  of  the  ovary  into 
cysts  of  the  stroma  lined  by  ciliated  epithelium.  As  a  result,  Olshau- 
sen, in  1886,  abandoned  the  theory,  since  when  it  has  been  discarded. 
Occasionally,  it  is  revived  without  much  supporting  evidence.  As 
recently  as  1919,  Gordon  Ley  classified  papillary  cysts  and  carcinoma 
as  derivatives  of  wolffian  tissues  without,  however,  advancing  any 
proof  of  origin. 

There  is  considerable  evidence  to  affirm  that  ovarian  cysts  can  arise 
from  germinal  epithelium.  Waldeyer  first  demonstrated  their  origin 
from  portions  of  Pfliiger's  ducts  which  were  remnants  either  from 
fetal  life  or  new  formed  in  the  adult  by  the  downgrowth  of  the  super- 
ficial ovarian  epithelium.  These  observations  have  since  been  con- 
firmed by  numerous  students  and  recently  by  Goodall  after  an  exten- 
sive study  of  human  and  animal  ovaries  of  various  age.  Bauer  also 


TUMORS    OF    THE    OVARY  333 

describes  a  tumor  which  arose  from  downgrowths  of  the  surface 
epithelium. 

Ovarian  cysts  may  arise  from  the  superficial  ovarian  epithelium 
as  has  been  demonstrated  by  Pick  and  others.  Graves,  especially, 
gives  convincing  proof  in  two  instances  that  papillary  serous  cystade- 
noma  may  arise  from  this  layer.  One  growth  was  inverting  and  the 
other  was  everting,  and  both  were  traced  to  the  germinal  epithelium 
of  the  surface  and  to  its  inclusions  within  the  stroma.  Voigt's  case 
was  found  to  develop  from  the  surface  epithelium,  although  its  mor- 
phology suggested  a  follicular  origin.  De  Sinety  and  Mallasez,  and 
Flaischen,  have  also  described  tumors  lined  by  ciliated  epithelium 
which  developed  from  the  germinal  epithelium  of  the  surface  of  the 
ovary.  These  numerous  observations  are  strengthened  by  the  fact 
that  there  are  several  different  types  of  cells  in  the  germinal  epithelium. 
Walthard  recognized  ciliated  columnar  epithelial  cells,  small  masses 
of  cubical  cells,  and  cells  of  the  goblet  type  in  addition  to  the  typical 
germinal  epithelium.  Walthard  concluded  that  the  atypical  cells  were 
misplaced  rests,  a  tenet  that  is  not  accepted  by  all  others.  Walthard's 
goblet  cells  in  the  germinal  epithelium  are  at  present  advocated  as 
the  origin  of  pseudomucinous  cystadenoma.  All  do  not  agree,  how- 
ever. Pfannenstiel  believes  that  they  develop  from  the  follicle. 

Pseudomucinous  Cystadenoma. — The  great  majority  of  ovarian 
cysts  are  said  to  belong  to  this  group,  although  all  students  do  not  agree. 
Pfannenstiel  states  that  they  form  two-thirds  of  the  ovarian  cystoma, 
but  Graves,  in  his  recent  text,  states  that  they  were  slightly  less  frequent 
than  the  serous  growths  in  his  se-ries.  They  may  occur  at  any  time 
from  puberty  to  advanced  age,  but  are  more  common  between  the  ages 
of  thirty  and  forty-five  years.  It  is  generally  believed  that  they  occur 
more  frequently  in  unmarried  and  sterile  women. 

The  tumors  vary  greatly  in  size  and  structure  and  may  attain  mo^t 
extraordinary  dimensions.  The  largest  tumor  of  which  we  have  found 
record  was  estimated  by  Spohn  to  weigh  328  pounds.  Barlowe's  tumor 
weighed  298  pounds  and  there  are  8  others  which  we  have  found  to 
weigh  more  than  200  pounds.  We  have  reviewed  this  subject  in  the 
chapter  on  mammoth  ovarian  tumors  (page  403).  The  cysts  usually 
occupy  most  of  the  substance  of  the  ovary,  although  a  small  part  of 
that  organ  is  generally  spread  out  on  one  small  portion  of  the  surface  of 
the  tumor.  The  cystadenomata  are  sometimes  quite  small,  and  may 
occasionally  push  their  way  into  the  ovarian  and  broad  ligaments. 

The  tumor  is  usually  unilateral  and  appears  as  a  rounded  or  oval 
mass  covered  by  a  smooth,  glistening,  pearly  gray  capsule.  It  often 
contains  irregular  bosses  and  presents  distinct  globules.  Large  blood 
vessels  are  rarely  seen  on  the  surface.  The  cyst  is  usually  fluctuant, 
especially  when  there  is  one  large  compartment.  They  are  generally 
pedunculated  and  the  pedicle  is  composed  of  broad  ligament,  fallopian 


334 


PELVIC   NEOPLASMS 


tube,  and  ovarian  ligament.  In  about  10  per  cent  of  cases,  they  pre- 
sent as  intraligamentous  growths.  Both  ovaries  are  involved  in  from 
15  to  20  per  cent  of  cases. 

The  tumors  are  always  multilocular  and  are  composed  of  numerous 
cysts.  The  smaller  the  tumor,  the  more  uniform  size  are  the  cysts. 
The  larger  tumors  usually  contain  a  few  cysts  of  very  large  size,  which 
have  developed  at  the  expense  of  the  smaller  ones  which  are  com- 
pressed in  the  tumor  wall.  Pressure  of  neighboring  cysts  upon  the 


FIG.  69. — MULTILOCULAR  PSEUDOMUCINOUS  CYST  OF  OVARY  THE  SIZE  OF  A    Six  MONTHS 

PREGNANCY. 

partition  wall,  which  separates  them,  often  ruptures  it.  Occasionally, 
smaller  cysts  project  into  larger  ones  and,  by  rapid  growth,  tend  to 
obliterate  the  cavity.  Sometimes  a  large  part  of  the  tumor  mass  is  com- 
posed of  a  fine,  honeycombed  meshwork  of  glands  and  minute  cysts 
which,  at  first  sight,  suggests  malignant  degeneration.  Expression  of 
the  cyst  contents  shows  that  the  inner  walls  are  smooth  and  present 
the  picture  of  a  simple  cystic  adenoma.  Yet,  scanty  low  papillary 
nodules  may  project  into  the  cavity.  In  one  group  of  cases,  the 
papillary  pseUdomncinoiis  cystadenoma,  the  projections  are  well  developed. 


TUMORS    OF    "?HE    OVARY  335 

The  surface  of  the  cyst  is  usually  remarkably  free  from  adhesions. 
Frequently  there  are  large,  dense,  fibrous  plaques  upon  the  outer  surface, 
and,  occasionally,  areas  of  calcification.  On  cut  section,  the  cyst  wall  is 
found  to  consist  of  firm,  fibrous  tissue,  usually  4  or  5  millimeters  in  thick- 
ness. The  intercystic  septa  are  generally  delicate  and  transparent  and  are 
lined  with  a  smooth  and  glistening  membrane.  They  are  sometimes  studded 
with  minute  granular  elevations,  yet  definite  papillary  ingrowths  are  not 
often  noted.  A  fine  crystalline  deposit  is  often  present  on  the  inner  surface 
as  well  as  pigmented  areas  which  have  resulted  from  minute  hemorrhage. 

MICROSCOPIC  STRUCTURE. — The  outer  surface  of  the  tumor  is  covered 
with  low  cubical  or  flattened  epithelium  derived  from  the  germinal  layer. 
The  cyst  wall  consists  of  fibrous  tissue  arranged  in  two  or  three  parallel 
layers.  The  outer  layers  are  distinctly  fibrous  and  contain  few  cellular 
elements,  but,  toward  the  inner  surface,  there  are  many  oval  and  fusiform 
cells  which  present  in  some  places  the  appearance  of  normal  ovarian  stroma. 
Smooth  muscle  fibers  may  be  found  near  the  pedicle.  In  the  vicinity  of  the 
hilus,  young  follicles,  corpora  lutea,  and  fibrous  bodies  usually  can  be  seen. 

The  inner  wall  of  the  cyst  is  covered  with  cylindric  cells  which 
vary  in  height  according  to  the  amount  of  pressure  upon  them.  The 
nuclei  are  small  and  basal,  and  the  cytoplasm  is  clear  and  transparent. 
They  resemble  mucous  cells,  and  goblet  cells  may  be  abundant.  Papil- 
lary outgrowths  are  very  rare.  They  vary  in  shape  but  are  usually 
warty  and  dendriform.  The  connective  tissue  stroma  of  these  pro- 
jections is  usually  thin  and  vascular  but  may  be  dense  and  firm. 
Rarely  it  appears  myxomatous. 

Degenerative  processes  are  not  uncommon.  Fatty  degeneration 
may  occur,  especially  in  the  epithelial  lining,  but  may  be  present  in  the 
walls  of  the  septa.  Areas  of  calcification  are  especially  apt  to  be  seen 
when  the  nutrition  of  the  tumor  has  been  affected  by  a  slow  torsion 
of  the  pedicle.  Atheromatous  changes  are  sometimes  found  and  in- 
farcts  are  not  uncommon. 

The  contents  of  the  cysts  vary  considerably,  although  they  are 
generally  ropy  and  gelatinous.  The  fluid  in  the  larger  cysts  is  usually 
thinner  than  in  the  smaller  cavities.  It  may  be  so  tenacious  in  the 
latter  that  it  can  be  expressed  only  with  difficulty.  Remnants  of  the 
partition  walls  which  have  been  broken  down  from  pressure  may  be 
present  in  the  secretion,  appearing  as  masses  of  fibrous  tissue.  When 
they  have  degenerated,  they  may  show  only  as  whitish  lines  running 
through  the  gelatinous  fluid.  Sometimes  altered  blood  may  be  found 
in  the  fluid;  rarely  pus  may  be  present  also.  The  specific  gravity  varies 
from  i.oio  to  1.030. 

The  chemical  reaction  may  be  either  neutral  or  alkaline.  The  solids 
consist  of  proteid,  fats  and  salts  and  constitute  from  one-tenth  to  one- 
twentieth  of  the  contents  of  the  cyst.  Pseudomucin  is  the  character- 
istic content  of  the  tumor.  It  is  a  glycoproteid  which  differs  from 


33 6  PELVIC  NEOPLASMS 

mucin  in  that  it  is  not  precipitated  by  acetic  acid.  In  its  pure  state, 
it  has  a  clear,  glassy  transparency.  It  is  most  abundant  in  the  small 
cysts  with  colloid  contents.  The  color  may  be  considerably  altered 
by  transudates  which  occur  from  the  blood  vessels  as  the  result  of 
torsion  and  by  necrotic  changes  in  the  cyst  wall.  Thus,  the  color  may 
range  from  white  to  yellowish,  or  greenish  gray,  or  even  to  a  dusty 
brown  or  black  color.  The  greenish  yellow  color  is  due  to  cholesterin 
which  gives  it  a  shimmering  hue.  The  darker  colors  are  due  to  altered 
blood.  Microscopically,  we  find  no  pathognomonic  cells.  There  may 
be  more  or  less  degenerated  epithelial  cells,  leukocytes,  or  granular 
masses  of  pigment,  blood  corpuscles  or  cholesterin  plates.  Sodium 
chlorid  is  the  most  abundant  salt,  but  alkaline  and  earthy  phosphates 
may  be  present.  Cholesterin,  lucin,  urea,  cystin  and  allantoin  have 
also  been  demonstrated. 

The  tumor  is  not  often  subject  to  malignant  degeneration.  Carcino- 
mata  have  been  found  in  only  one  and  a  half  to  two  per  cent  of  cases, 
usually  developing  in  the  scar  of  the  stump  from  which  the  cyst  has  been 
removed.  It  generally  leads  to  death  in  from  two  to  three  years.  The 
other  ovary  develops  the  disease  in  about  2  per  cent  of  cases. 

Solid  Adenomata. — This  type  is  not  a  distinct  pathological  entity, 
since,  while  macroscopically  solid,  they  are  in  reality  pseudomucinous 
cystadenomata.  They  constitute  about  3  per  cent  of  the  cystadeno- 
mata.  Minute  examination  shows  that  they  are  parvilocular,  pseudo- 
mucinous cystadenomata  presenting  a  fine  honeycombed  texture  of 
minute  cysts  filled  with  a  firm  pseudomucinous  secretion.  They  are 
far  more  cellular  than  the  ordinary  cystic  growth  and  the  epithelium  is 
usually  atypical,  granular  and  over-nourished.  There  are  many  tran- 
sitional types  between  this  adenoma  and  the  solid  and  cystic  adeno-car- 
cinomata,  yet  solid  adenomata  may  attain  large  size  without  present- 
ing malignant  changes.  The  tumors  are  usually  accompanied  by  ascites. 

Cystadenoma  Serosum. — The  majority  of  observers  state  that  the 
serous  cysts  are  less  common  than  the  pseudomucinous.  Webster  says 
that  they  occur  only  one-eighth  as  frequently.  Ewing  claims  they  are 
found  one-half  as  frequently,  while  in  Graves'  series,  they  are  slightly 
more  numerous. 

They  usually  do  not  attain  the  large  size  of  the  pseudomucinous 
tumors,  and  form  swellings  rarely  exceeding  25  to  30  centimeters  in 
diameter.  Most  of  the  serous  ovarian  cysts  are  papillary  cystadenoma. 
About  one-half  of  the  papillary  forms  are  intraligamentous  growths. 
Often  they  develop  entirely  subserously  so  that,  when  they  attain 
large  size,  the  peritoneum  may  be  displaced  far  upward  and  the  neigh- 
boring organs  pushed  aside.  The  majority  of  all  the  serous  growths, 
however,  are  pedunculated  and  intraperitoneal. 

Externally,  the  serous  cysts  closely  resemble  the  pseudomucinous 
variety.  They  are  also  multilocular,  although  the  component  cysts  are 


337 


fewer  in  number  than  in  the  pseudomucinous  type.  In  more  than  one- 
third  of  cases,  they  appear  macroscopically  as  unilocular  growths, 
yet  evidence  of  daughter  cysts  may  be  obtained  by  microscopic  study. 
The  tumors  are  often  bilateral  and  it  is  said  that  60  per  cent  of  the 
actively  growing  papillary  forms  affect  both  ovaries,  either  as  primary 
tumors,  or  through  implantations.  The  process  may  not  be  contem- 
poraneous, however,  a  fact  which  must  be  kept  in  mind  by  the  surgeon. 
Most  of  the  serous  cystadenomata  show  papillary  outgrowths  of 
the  lining  epithelium,  which  may  appear  both  in  the  inner  lining  of 
the  cyst  spaces,  or  upon  the  outer  surface  of  the  tumor.  The  latter 


FIG.  70. — PAPILLARY  SEROUS  CYST-ADENOMA.     Showing  cauliflower  masses  which  had  not 

broken  through  the  capsule, 

may  arise  by  perforation  of  the  cyst  wall  and  evagination  of  the  growth, 
or  by  independent  growth  upon  the  outer  surface  of  the  tumor.  In 
about  10  per  cent  of  cases,  the  growth  consists  entirely  of  surface 
papilloma.  These  tumors  are  rarely  larger  than  the  size  of  a  fist. 

The  papillary  processes  vary  in  form.  They  may  present  as  warty 
excrescences  or  as  dendriform  branchings  arising  from  a  pedicle.  They 
vary  in  color  from  white  to  red  and  often  contain  calcerous  deposits 
which  may  be  concentrically  arranged  (psammona).  The  papillary 
processes  are  usually  relatively  few  in  the  larger  tumors,  yet  small 
cysts  are  quite  likely  to  be  entirely  filled  with  them.  The  stroma  of 
the  papillae  consists  of  vascular,  delicate  connective  tissue,  surmounted 


338  PELVIC  NEOPLASMS 

by  cuboid  or  columnar  epithelium,  which  is  often  ciliated.  The  nuclei 
are  large  and  densely  staining.  Serum  is  often  present  in  the  basal 
connective  tissues.  The  blood  vessels  are  subject  to  hyaline  degener- 
ation. 

As  the  papilloma  grow,  the  epithelial  cells  rapidly  hypertrophy  and 
present  irregular  proliferations  upon  the  connective  tissue  stalk.  As 
a  result,  they  form  secondary  papillae,  giving  the  wall  a  honeycombed 
appearance,  so  that  sections  of  compact  papillae  may  present  a  gland- 
ular appearance. 

The  cyst  contents  are  originally  yellowish,  alkaline,  serous  fluid, 
rich  in  albumin,  but  free  from  pseudomucin.  Later,  it  may  contain 
increasing  traces  of  pseudomucin,  epithelial  detritus,  fatty  substances, 
and  often  much  blood  from  the  rupture  of  the  delicate  vascular  papillae. 

The  papillary  growths  in  the  interior  of  the  cysts  may  perforate 
their  walls  and  extend  into  neighboring  cavities  and  also  the  outer 
cyst  wall,  and  appear  on  the  peritoneal  surface  of  the  tumor.  In  event 
of  the  latter  complication,  the  papillary  processes  may  fasten  the  tumor 
to  the  adjacent  organs,  as  the  uterus,  rectum,  bladder,  and  pelvic  floor. 
If  the  rupture  has  occurred  into  the  free  peritoneal  cavity,  the  growth 
usually  becomes  quickly  disseminated  by  the  formation  of  so-called 
implantation  metastases.  Sometimes  these  implantations  do  not  de- 
velop until  some  years  after  rupture,  although  the  ascitic  fluid 
contained  detached  papillary  fragments.  Ascites  is  a  regular  accom- 
paniment of  secondary  implantations. 

In  a  small  proportion  of  cases,  the  metastases  disappear  after 
extirpation  of  the  primary  tumor,  proof  of  which  has  been  obtained  by 
subsequent  laparotomy.  Pfannenstiel  collected  a  dozen  such  cases 
from  the  literature.  The  anatomical  process  in  each  case  was  the  same 
— the  papillary  nodules  flattened  out,  became  transformed  into  white 
spots  and  radiating  scars,  and  finally  disappeared  entirely,  apparently 
by  a  reactive  peritonitis. 

Yet  this  favorable  termination  is  not  to  be  expected,  since  the 
implantations  are  far  more  likely  to  survive  on  a  low  grade  of  nutrition 
for  a  long  time,  and  suddenly  assume  active  growth  and  extend  over 
much  of  the  peritoneum.  Adhesions  and  ascites  are  invariable  accom- 
paniments. The  process  may  last  for  many  years  and  may  be  attended 
by  a  progressive  anemia  and  emaciation.  The  peritoneum  finally 
becomes  so  altered  that  there  is  grave  disturbance  of  the  intestinal 
functions.  Death  finally  occurs  from  cachexia  or  intercurrent  disease. 

Thus  it  will  be  seen  that  these  tumors  lie  at  the  border  line  of 
malignancy.  Although  not  causing  local  destruction  of  neighboring 
tissues,  or  metastasizing  through  blood  or  lymph  vessels,  they  extend 
by  direct  contact.  Indeed,  some,  as  Pfannenstiel,  claim  that  50  per  cent 
of  these  cases  are  really  malignant.  Later  observers  do  not  support 
this  view. 


TUMORS    OF    THE    OVARY  339 

Papillary  cysts  early  give  rise  to  symptoms  when  they  are  inter- 
ligamentary  or  if  accompanied  by  ascites. 

They  should  be  removed  through  the  abdominal  route  without 
puncture  of  the  cyst  in  order  to  limit  the  chance  of  implantations.  The 
opposite  ovary  should  be  carefully  inspected  to  ascertain  its  condition. 
If  cystic,  it  should  be  removed  together  with  the  uterus.  . 

The  tumor  may  recur  after  operation  in  the  form  of  papillary  nod- 
ules about  the  stump,  in  the  abdominal  wound,  or  on  the  peritoneum. 
Recurrences  are  seldom,  unless  the  tumor  has  broken  through  its 
capsule.  The  majority  of  recurrences  follow  the  removal  of  intraliga- 
mentous  growths  which  have  presented  technical  difficulties.  Recur- 
rences have  been  observed  as  late  as  twelve  years. 

Pfannenstiel  states  that  77  per  cent  remain  cured  five  years  after 
removal,  yet  the  period  of  observation  should  not  end  at  this  time 
because  of  the  likelihood  of  even  later  recurrence. 

In  direct  contrast  to  the  papillary  forms,  the  simple  serous  adeno- 
mata are  clinically  benign.  They  grow  very  slowly,  are  usually  uni- 
lateral, cause  no  metastases  and  do  not  recur  after  operation.  Symp- 
toms are  unusual,  except  after  torsion,  since  they  are  rarely  intraliga- 
mentous  and  do  not  cause  ascites. 

Racemose  Ovarian  Cysts. — This  rare  type  of  cystic  ovarian  tumor 
was  first  described  by  Koeberle  in  1871.  It  is  seldom  seen,  since  Jayle 
and  Bender,  in  1903,  were  able  to  find  but  17  cases  reported  in  the  liter- 
ature when  reporting  their  case.  It  is  often  termed  grapelike  cystoma, 
since  it  is  a  multilocular  tumor,  consisting  of  a  mass  of  vesicles  loosely 
united,  some  arising  from  pedicles  given  off  from  others  springing  from 
the  ovary,  or  from  supernumerary  ovaries  contained  in  the  broad  liga- 
ment. The  mass  suggests  an  atypical  hydatidiform  mole,  although  the 
vesicles  vary  greatly  in  size.  The  largest  vesicle  in  a  case  reported  by 
Hellier  and  Smith  contained  more  than  200  cubic  centimeters  of  fluid, 
while  others  held  only  a  few  cubic  centimeters.  The  wall  of  each 
vessel  is  usually  thin  and  somewhat  translucent.  It  is  lined  by  a  single 
layer  of  cells,  which  may  be  columnar,  cubic,  or  flattened.  The  col- 
umnar cells  are  generally  ciliated.  The  fluid  content  is  limpid  and 
yellow,  and  contains  a  trace  of  albumin  and  chlorids.  They  are  sup- 
posed to  develop  from  the  germinal  epithelium  of  the  surface  of  the 
ovary. 

Myxomatous  Degeneration  of  Surface  Papillae. — This  form  is 
rather  more  common  than  the  preceding.  It  presents  as  a  grapelike 
growth  which  is  believed  to  arise  from  myxomatous  degeneration  of 
superficial  papillae  of  papillary  cystadenomata  of  the  surface  of  the 
ovary.  The  tumors  are  not  true  cysts,  since  they  are  composed  of 
myxomatous  stroma  elements  covered  with  surface  epithelium  derived 
from  the  covering  of  the  ovary.  They  are  easily  detached  from  the 
main  tumor,  when  they  float  free  in  the  ascitic  fluid  which  usually 


340  PELVIC  NEOPLASMS 

accompanies  them.  They  may  give  rise  to  peritoneal  implantations. 
Fritsch  reoperated  a  case  twenty  years  after  removal  of  the  primary 
tumor,  and  similar  observations  have  been  recorded  by  others. 
Schroeder  reported  a  case  which  underwent  carcinomatous  degenera- 
tion. 

Other  Adenomata. — The  superficial  or  everting  papillary  adenoma 
may  also  present  as  a  solid  tumor.  Small  growths  are  fairly  common, 
although  large  ones  are  rare.  The  growth  is  essentially  benign,  since 
many  cases  have  been  extirpated  without  recurrence. 

Adenofibromata  have  also  been  described.  They  usually  present 
scattered  glandlike  formations  in  the  substance  of  the  fibromatous 
tumor.  These  are  believed  to  arise  from  invagination  of  germinal  epi- 
thelium. Inclusions  resembling  endometrium  have  been  described  by 
Pick,  Pfannenstiel,  Russell,  and,  quite  recently  by  Norris. 

Epithelial  alveoli  are  occasionally  seen  in  true  ovarian  fibromata. 
They  may  undergo  a  cystic  dilatation  and  subsequent  carcinomatous 
change. 

OVARIAN  CARCINOMA 

It  is  rather  difficult  to  determine  the  frequency  of  true  ovarian  car- 
cinoma, since  many  of  the  statistics  are  incomplete,  and  others  include 
the  malignant  degenerations  of  ovarian  tumors  that  are  ordinarily 
benign.  Schmidlechner,  of  Budapest,  records  720  ovariotomies  done  in 
a  series  of  50,000  gynecologic  patients  between  1880  and  1904.  Of 
these,  147  were  done  for  malignant  tumors.  Sixty  proved  to  be  adeno- 
cystomata  that  had  undergone  malignant  changes;  52  were  primary 
carcinomata.  Ewing,  combining  Martin's  and  Libbert's  statistics, 
states  that  22  per  cent  of  more  than  200  cases  of  ovarian  tumors  were 
carcinomatous. 

Etiology. — The  etiology  is  not  known.  Carcinomata  develop  from 
epithelial  elements  in  the  ovary,  yet  we  do  not  know  which  group  of 
cells  is  more  likely  to  be  altered.  The  earlier  theories  attempted  to 
correlate  carcinomata  with  the  lining  of  the  graafian  follicle  because  the 
histologic  features  of  some  of  the  ovarian  cancers  appeared  to  repro- 
duce both  the  primordial  and  growing  graafian  follicles.  This  theory 
was  first  advanced  by  Accorici  in  1890  and  has  later  had  the  support  of 
Emanuel,  von  Kahlden,  Pozzi,  Beassenat,  Gottschalk,  Schroeder  and 
Delepine.  Others,  however,  urge  that  since  the  ovules  and  primordial 
follicles  are  formed  during  embryonic  life,  it  is  not  likely  that  their  features 
could  be  reproduced  even  by  a  pathologic  process  at  a  later  period.  A  large 
number  of  the  more  recent  authors,  including  Voigt,  Pollano,  Blau  and 
Ingier,  believe  the  structures  which  resemble  primordial  follicles  in  the 
folliculoma  group  of  cancers  are,  in  reality,  degenerative  processes  in  the 
center  of  the  carcinomatous  alveolus  about  which  the  surrounding  epi- 


TUMORS    OF    THE    OVARY  341 

thelium  presents  a  radial  arrangement.  Although  some  ovarian  cancers 
may  contain  alveoli  which  closely  resemble  a  graafian  follicle,  similar  struc- 
tures have  been  described  in  carcinoma  in  other  organs,  as  has  been  demon- 
strated by  Lipmann.  There  remains,  therefore,  the  possibility  that  cancers 
may  arise  from  Pfliiger's  tubes,  germinal  epithelial  rests  as  claimed  by 
Walthard,  miillerian  structures,  or  from  invaginations  of  the  germinal  epi- 
thelium, a  view  which,  at  the  present  time,  is  favored  by  many  labora- 
tory workers. 

The  studies  of  histogenesis  indicate  that  developmental  anomalies  are 
probably  responsible  for  the  majority  of  the  tumors,  since  other  predispos- 
ing factors  do  not  appear  likely.  Trauma,  which  is  often  considered 
important  in  tumors  of  the  exposed  surfaces,  cannot  be  a  factor  because  of 
the  protected  position  of  the  ovaries.  Inflammatory  changes  are  probably 
not  of  much  importance,  since  Massabuau  and  Etienne  could  obtain  a  his- 
tory of  an  inflammatory  condition  in  only  10  of  250  cases.  The  influence 
of  heredity  has  not  been  proved,  since  it  was  demonstrated  in  only  6  cases 
of  the  same  series.  Proper  family  histories,  however,  are  very  difficult  to 
obtain.  The  patient's  occupation  did  not  seem  to  be  of  importance.  Hein- 
rich  claimed  that  ovarian  cancers  usually  occurred  in  married  women, 
whereas  the  benign  tumors  \vere  more  likely  to  occur  in  the  unmarried.  This 
observation  has  not  been  confirmed.  Massabuau  and  Etienne  tabulated 
their  cases  to  determine  whether  pregnancy  was  a  factor  but  were  unable 
to  reach  definite  conclusions.  Excluding  the  cases  which  were  too  young  to 
have  had  children,  they  found  that  97  had  been  pregnant,  whereas  26 
had  not.  Nine  cases  had  had  only  one  child  while  the  others  had  had 
several.  One  case  had  had  n  children.  Eleven  cases  had  had  abor- 
tions, one  having  had  3.  All  the  pregnancies  had  been  normal  except 
one  which  had  had  hydramnios.  Only  i  case  had  had  an  instrumental 
delivery.  The  pregnancies  very  often  antedated  by  many  years  the 
development  of  the  cancer. 

Age. — Cancers  of  the  ovary  have  been  observed  at  various  ages 
ranging  from  four  to  sixty-nine  years,  although  the  great  majority  occur 
between  the  fourth  and  sixth  decades.  Olshausen  claimed  that  carcinoma 
developed  very  frequently  in  very  young  children,  yet  others  state  that  the 
majority  of  these  cases  are  sarcoma.  Massabuau  and  Etienne  collected  13 
cases  occurring  before  puberty,  69  cases  during  active  menstrual  life,  and  38 
cases  after  the  menopause.  The  Krukenberg  tumors  occur  fairly  early,  since 
the  majority  are  observed  during  the  third  decade.  Scirrhods  cancers  are 
most  frequent  after  sixty,  and  may  develop  so  insidiously  that  they  are 
first  discovered  at  post  mortem. 

Classification. — There  is  considerable  difficulty  in  classifying  ovarian 
carcinoma,  because  of  the  large  number  of  atypical  growths  that  do  not 
fit  readily  into  any  grouping.  The  great  majority  of  ovarian  tumors  are 
primary  in  the  ovary.  A  very  large  proportion  of  these  arise  dc  noi'o  from 
apparently  normal  organs.  The  larger  number,  however,  result  from  car- 


342  PELVIC  NEOPLASMS 

cinomatous  changes  in  growths  which  were  originally  benign.  The  older 
authors  attempted  the  division  of  all  of  the  ovarian  cancers  into  solid  and 
cystic  carcinomata.  This  has  not  proved  satisfactory,  because  of  the 
frequency  with  which  large  cellular  growths,  originally  solid,  break  down 
and  undergo  cystic  changes.  There  are  also  a  number  of  cancers  which 
merit  special  consideration  because  of  distinctive  features  of  growth  or 
etiology.  Thus,  in  addition  to  the  solid  and  cystic  ovarian  cancers,  we 
should  consider  the  folliculoma  malignum,  the  squamous  cell  carcinoma,  the 
clear  cell  cancer,  the  carcinoma  mucocellulare  of  Krukenberg,  and  other 
and  presumably  metastatic  cancers. 

Solid  Ovarian  Carcinoma. — This  group  forms  about  15  per  cent  of 
ovarian  cancers.  They  may  be  primary  growths,  yet  are  often  metastatic. 
They  may  be  subdivided,  according  to  their  morphology,  into  two  groups: 
( i )  the  alveolar  or  medullary  carcinoma,  characterized  by  its  alveolar  struc- 
ture, soft  consistency  and  scanty  fibrous  tissue  stroma;  and  (2)  the  scir- 
rhous  tumor  which  is  dense  and  fibrous  and  contains  a  relatively  small 
amount  of  epithelial  cells.  The  genuine,  or  idiopathic,  carcinoma  of  Geb- 
hard  forms  the  majority  of  the  medullary  carcinoma.  While  originally 
solid,  the  larger  medullary  growths  are  likely  to  present  late  in  their  devel- 
opment cystic  areas  which  result  from  degeneration. 

The  size  of  these  tumors  varies  between  rather  wide  limits,  although  they 
are  usually  small  and  seldom  exceed  an  infant's  head  in  dimensions.  They 
may,  however,  develop  into  very  large  growths.  Massabuau  and  Etienne 
record  one  which  was  as  large  as  a  uterus  at  term  and  weighed  6  kilograms. 
The  largest  tumor  of  which  we  find  record  is  Gebhard's,  weighing  7,300 
grams. 

The  tumors  are  at  first  unilateral,  yet  the  second  ovary  has  become 
involved  in  nearly  50  per  cent  of  cases  by  the  time  the  case  comes  to 
operation.  They  are  usually  pedunculated  and  lie  at  first  in  the  pelvis  to 
arise  subsequently  into  the  lower  abdomen.  Originally  free,  the  growth 
later  becomes  fixed  by  adhesions  of  inflammatory  or  neoplastic  origin.  The 
pedicle  is  usually  short  and  torsion  is  not  common.  The  growth  seldom 
develops  within  the  broad  ligament.  Massabuau  and  Etienne  found  only 
14  such  cases  in  250  carcinoma.  Strange  to  say,  Schmidlechner's  series  of 
33  cases  contained  9  of  these,  while  the  other  5  were  scattered  among  the 
remaining  217. 

The  solid  tumors  are  usually  irregularly  rounded  in  form.  They  are 
seldom  spherical.  Early  growths  may  retain  the  shape  of  the  normal 
ovary.  Sometimes  the  tumor  mass  may  be  divided  into  distinct  lobules  by 
deep  furrows.  The  surface  of  the  tumor  is  grayish  pink  in  color,  and,  in  its 
early  stages,  is  smooth  and  without  adhesion  formation.  Large  flat  veins 
may  be  seen,  beneath  the  surface  of  larger  tumors.  Later  in  its  develop- 
ment, the  growth  breaks  through  the  capsule  and  presents  yellow  trans- 
lucent cancerous  masses,  or  a  softer  brainlike  substance  which  oozes  out 
between  the  connective  tissue  fibers. 


TUMORS    OF    THE    OVARY 


343 


The  outer  capsule  is  derived  from  the  tunica  albuginea.  It  consists 
of  a  connective  tissue  membrane  averaging  4  or  5  millimeters  in  thickness. 
On  gross  section,  the  tumor  appears  homogeneous  and  of  a  yellow  gray 
color,  yet  careful  examination  shows  pea-  to  egg-sized  cancerous  areas 
in  the  midst  of  rather  edematous  connective  tissue  fibers.  There  may  be 
small  cysts,  in  the  larger  of  these  areas  which  contain  yellow  fluid 
discolored  by  hemorrhage.  They  are  lined  by  an  irregular  wall  of  soft, 
friable  tissue,  suggesting  that  the  cysts  arise  by  necrosis  and  liquefaction. 
Rarely  there  are  true  cysts  lined  by  epithelium  lying  near  the  surface  of 


FIG.  71. — SOLID  OVARIAN  CANCER,  SIRRHOUS  TYPE.     Developing  in  ovary  following  supra- 
vaginal  hysterectomy  for  uterine  fibroids. 

the  tumor.    The  tumor  itself  may  be  mottled  by  hemorrhage  so  that  it  gives 
an  appearance  like  marble. 

Morphologically,  there  are  a  confusing  variety  of  forms,  yet  the  major- 
ity of  the  cancers  present  an  alveolar  type.  The  cancer  cells  are  arranged 
in  small,  solid  cords,  usually  without  definite  lumen,  lying  in  a  fine,  delicate, 
connective  tissue  stroma.  The  outlines  of  the  alveoli  cannot  be  determined 
in  all  sections  and  the  growth  may  strongly  suggest  a  round  cell  sarcoma, 
yet  examination  of  other  slides  discloses  the  true  nature  of  the  tumor.  The 
cancer  cells  are  polygonal  in  type,  but  when  rapidly  growing  may  be  quite 
irregular. 


344 


PELVIC   NEOPLASMS 


In  one  type  of  growth',  the  cells  masses  are  arranged  like  tubules. 

The  pure  medullary  type  has  large  broad  columns  which  frequently 
anastomose  and  which  are  composed  of  small  polyhedral,  or  rounded, 
opaque,  granular  cells.  The  connective  tissue  stroma  is  scanty  and  has 
few  small  nuclei. 


FIG.  72. — SOLID  OVARIAN  CARCINOMA,  MEDULLARY  TYPE.  Macroscopically  the  tumor 
suggested  a  hemorrhagic  follicle  cyst.  The  tube  and  ovary  were  removed.  The  patient 
remains  well  after  four  years. 

A  rather  rare  variety  of  medullary  carcinoma  has  many  large,  clear 
cells  which  resemble  ova.  They  are  scattered  through  the  tumor  at  ex- 
tremely regular  intervals  and  bear  a  striking  resemblance  to  young  develop- 
ing follicles.  Occasionally,  the  whole  tumor  seems  to  be  composed  of 
myriads  of  slightly  dilated  normal  follicles.  Emanuel  believed  that  these 
cases  developed  from  malignant  changes  in  primordial  ova,  yet  this  view  is 
not  accepted  by  most  recent  observers.  The  cells  strongly  suggest  cross 


TUMORS    OF    THE    OVARY 


345 


sections  of  mutinous  stroma  and  the  majority  ascribe  such  an  origin  to  the 
tumor. 

The  scirrhous  type  present  only  fine  strands  of  epithelium  in  a  com- 
paratively dense,  fibrillated  stroma.  The  epithelium  is  arranged  in  single  or 
double  rows  of  cells  and  occasionally  in  small  nests  or  glandlike  structures. 
Some,  as  Orthmann,  believe  that  they  may  arise  from  degenerations  of  the 
downgrowth  of  germinal  epithelium  into  ovarian  fibroids.  They  may  also 
arise  from  carcinomatous  change  in  the  glandular  epithelium  of  fibro- 
adenoma.  The  majority  of  scirrhous  growths  are  not  primary  but  are 
metastatic  tumors.  They  are  usually  bilateral. 


FIG.  73. — SOLID  OVARIAN  CARCINOMA,  MEDULLARY  TYPE.     On  section  of  the  tumor  (Fig.  7 z  N, 
a  hemorrhagic  mass  escaped  consisting  largely  of  cancerous  tissue. 

Cystic  Carcinoma. — Cystic  carcinoma  may  develop  as  a  primary 
process  in  which  the  cysts  are  produced  by  the  secretions  of  the  cancerous 
cells ;  or  as  secondary  changes  in  cystic  tumors  that  were  primarily  benign. 
They  may  also  result  from  degenerative  changes  in  the  solid  cancerous 
tumors. 

The  cystic  adenocarcinoma  may  be  divided  into  two  types  correspond- 
ing to  the  two  types  of  benign  cystadenoma,  i.e.,  adenocarcinoma  papillare, 
and  adenocarcinoma  pseudomucinosum.  The  former  is  far  more  common. 

The  adenocarcinomata  papillare  form  a  most  interesting  group.  They 
reproduce  in  gross  structure  the  essential  features  of  the  papillary  cystad- 


346  PELVIC  NEOPLASMS 

enoma.  Some  indeed,  as  Pfannenstiel,  believe  that  cancerous  changes 
may  be  found  in  nearly  50  per  cent  of  the  tumors  which  are  ordinarily 
classed  as  benign,  a  point  not  conceded  by  Gebhard  and  many  other  later 
students. 

In  their  macroscopic  appearance,  the  carcinomatous  papillomata  re- 
semble the  serous  cystadenomata,  yet,  as  a  general  rule,  the  malignant  areas 
may  be  easily  recognized  by  the  naked  eye.  The  tumors  rarely  attain  the 
size  of  the  large  cystadenoma  and  are  seldom  larger  than  10  or  15  centi- 
meters in  diameter.  Some  are  pedunculated  and  freely  movable,  yet  the 
larger  number  is  either  intraligamentous  or  pedunculated  growths  which 
have  been  firmly  bound  down  by  adhesions.  The  capsule  of  the  larger 
growths  is  usually  perforated  and  covered  by  papillary  outgrowths  which 
have  developed  from  the  substance  of  the  tumor.  The  cancer  cells  have 
invaded  the  neighboring  peritoneum.  The  tumors  are  usually  bilateral,  yet 
one  side  is  often  histologically  benign,  while  the  other  side  is  frankly  car- 
cinomatous. Especially  interesting  is  the  development  of  malignancy  in  an 
ovary  which  appeared  perfectly  normal  at  the  time  its  fellow  was  removed 
because  it  was  cancerous. 

The  papillary  outgrowths  in  the  malignant  cyst  at  first  sight  appear  to 
exactly  resemble  those  of  the  benign  cysts.  Careful  macroscopic  examina- 
tion, however,  reveals  the  cellular  structure  and  their  true  character.  Pres- 
sure with  a  scalpel  allows  the  expression  of  the  milky  cancer  juice.  In 
other  cases,  the  papillary  structure  is  scarcely  visible  because  of  the  atypical 
growth  of  the  cells.  Minute  cysts  may  be  present  in  the  walls,  having  arisen 
from  seemingly  solid  nodules  which  sprang  from  proliferation  of  the  cells 
of  the  papillary  processes.  When  an  apparently  benign  cyst  is  becoming 
malignant,  the  cancerous  processes  will  be  surrounded  by  others  which  are 
seemingly  benign. 

The  solid  surface  papilloma  may  also  undergo  carcinomatous  degenera- 
tion and  become  transformed  into  typical  adenocarcinomatous  masses. 

The  contents  of  the  small  cysts  are  clear,  serous  fluid.  The  larger  cysts 
contain  turbid  material  from  desquamated  epithelium.  They  may  be  dis- 
colored by  hemorrhage. 

Microscopically,  these  tumors  present  the  typical  features  of  adeno- 
carcinoma,  often  showing  a  very  close  resemblance  to  the  adenocarcinoma 
of  the  uterine  body.  The  multiplication  of  cell  layers,  cohesion  of  adjoining 
papillae,  the  filling  of  intermediate  spaces  and  pseudo-alveoli  with  atypical 
cells,  are  usually  features  of  malignancy,  in  addition  to  the  basic  elements  of 
invasive  characteristics  and  evidence  of  rapid  cellular  reproduction. 

Not  all  tumors  assume  this  typical  form  and  mixed  types  are  very  com- 
mon. The  growths  may  be  composed  of  nonglandular,  solid  medullary 
masses,  containing  very  small  cystic  spaces  in  the  connective  tissue  frame- 
work. The  cysts  are  lined  by  a  many-layered  polymorphic  epithelial  cell. 
The  stroma  of  these  growths  varies  greatly.  Occasionally,  it  is  very  cellular 
and  mav  even  resemble  sarcoma.  Calcification  mav  occur  in  either  the  con- 


TUMORS    OF    THE    OVARY  347 

nective  tissue  stroma  or  the  epithelial  masses.     It  is  likely  to  be  laid  down 
as  concentrically  layered  psammoma  bodies. 

The  metastases  are  usually  local  as  in  the  adenomata.  They  also  are 
implantation  metastases  but  are  aggressive  and  never  spontaneously  dis- 
appear. They  spread  by  direct  extension,  even  through  the  diaphragm  and 
through  the  pleura.  They  are  accompanied  by  serous  effusions.  Intraliga- 
mentary  growths  less  frequently  produce  ascites.  Extensions  from  them 
fairly  permeate  the  neighboring  organs.  Lymphatic  or  bloodstream  metas- 
tases are  extremely  rare. 

Adenocarcinoma  Pseudomucinosum. — These  tumors  are  seen  very 
rarely.  A  few  are  probably  malignant  from  their  inception,  while  the 
majority  develop  because  of  malignant  changes  in  the  originally  benign 
cyst.  In  the  same  way,  implantations  or  recurrences  from  a  tumor  benign  in 
its  own  structure  may  develop  in  the  peritoneum,  the  operative  stump,  the 
abdominal  scar  and  suddenly  assume  a  carcinomatous  form.  Very  rarely, 
the  pseudomucinoma  peritonei  may  develop  malignancy. 

In  the  pseudomucinous  tumor,  also,  the  malignant  degeneration  may 
appear  as  papillary  excrescences,  yet  is  more  likely  to  present  as  a  prolifera- 
tion of  the  epithelial  lining  of  the  small  cysts  which  becomes  many  layered 
and  shows  marked  changes  in  cell  type.  The  cells  increase  in  number  and 
height,  lose  most  of  their  ability  to  secrete  mucus,  and  become  granular  and 
opaque,  with  large  nuclei  containing  abundant  chromatin.  Occasionally,  the 
walls  of  the  larger  cysts  are  transformed  into  thick  cancer  masses.  Rarely 
the  growth  is  more  diffuse  and  obscures  the  glandular  structure. 

Macroscopically,  the  cancerous  areas  appear  very  cellular  and  friable. 
While  they  are  not  easily  distinguished  with  the  naked  eye  from  benign 
tissue  composed  of  closely  packed  minute  cysts  of  microscopic  size,  they 
may  be  readily  differentiated  by  the  microscope.  The  large  cystic  spaces 
are  usually  preformed  but  may  arise  by  necrosis  of  cellular  cancerous  areas. 
The  latter  type  usually  contain  hemorrhages.  The  true  cysts  have  very 
little  mucous  secretion.  The  smaller  alveoli  have  more.  The  cyst  fluid  is 
usually  turbid  from  epithelial  debris  and  discolored  by  blood.  The  tumor's 
capsule  is  often  perforated  and  presents  a  cancerous  growth  upon  its  outer 
surface.  The  mass  is  bound  down  by  adhesions  and  surrounded  by  im- 
plantations. Metastases  in  the  regional  lymphatics  are  common.  Distant 
metastases  are  rarely  seen. 

Folliculoma  Malignum. — This  is  an  atypical  alveolar  carcinoma 
which  suggests  thyroid  tissue.  It  was  first  described  by  Gottschalk 
in  1899.  There  is  not  yet  complete  agreement  as  to  its  origin.  Gott- 
schalk believed  that  it  originated  from  the  follicle  and  was  comparable 
to  the  benign  graafian  follicle  adenoma  described  by  von  Kahlden. 
Pick  claims  that  it  is  a  carcinomatous  degeneration  of  an  ovarian 
struma  of  teratomatous  origin  in  which  the  other  teratomatous  ele- 
ments have  been  suppressed.  Both  Voigt  and  Bauer  proved  that  their 
cases  developed  from  the  germinal  epithelium. 


348  PELVIC   NEOPLASMS 

Gottschalk's  tumor  was  a  fist-sized,  grayish  white,  unilateral  growth 
which  had  involved  the  left  ovary  of  a  woman  of  forty-eight.  There  was 
marked  ascites  but  no  metastases  could  be  demonstrated.  The  cut  surface 
showed  numerous  minute  cysts,  particularly  in  the  cortex  of  the  tumor. 
The  tumor  was  very  vascular  and  showed  areas  of  interstitial  hemorrhage. 
The  stroma  was  not  cellular  and  contained  areas  of  hyaline  degeneration. 
The  parenchyma  consisted  of  sheets  of  protoplasm  without  definite  cell 
boundaries,  suggesting  thyroid  tissue.  The  small  cysts  in  the  center  of  the 
masses  contained  mucinous  material  and  resulted  from  cell  degeneration. 
The  microscopic  structure  resembled  struma  ovarii  which  may  form  a 
component  part  of  ovarian  teratoma.  Gottschalk  recognized  the  resem- 
blance but  ruled  out  struma,  because  there  were  no  other  teratomatous 
elements,  and  also  because  the  areas  suggesting  thyroid  were  not  primary 
features  of  the  tumor  but  were  the  result  of  secondary  cystic  degeneration. 

No  growth  yet  described  has  contained  iodin. 

Somewhat  similar  to  the  so-called  folliculoma  malignum  are  the  granu- 
losa  cell  carcinoma  described  by  Werdt  and  the  oophorim  follicnlare 
described  by  Brenner.  Both  of  these  tumors  gave  rise  to  multiple  small 
cysts  in  an  enlarged  ovary. 

Primary  Squamous  Cell  Epithelioma. — Primary  squamous  cell 
epithelioma  was  described  by  von  Hausemann.  He  believed  that  it  devel- 
oped from  a  metaplasia  of  ovarian  epithelium,  or  possibly  from  squamous 
epithelial  rests  which  were  described  by  Walthard.  An  ovulogenetic  origin 
is  not  probable,  since  there  were  no  other  teratomatous  elements  in  the 
ovary. 

Atypical  Forms. — There  are  a  number  of  types  of  ovarian  cancer 
which  are  not  clear  cut. 

The  first  group  present  features  which  suggest  an  endothelial  origin. 
Probably  many  of  the  so-called  ovarian  endothelioma  really  belong  in  this 
group.  The  cancers  are  alveolar  and  the  indistinct  alveoli  are  formed  by 
unusually  small  cells.  The  alveoli  vary  greatly  in  size.  The  cells  may  be 
arranged  about  blood  vessels,  or  there  may  be  areas  of  diffuse  growth  where 
the  epithelium  is  intimately  mingled  with  the  stroma  or  appears  in  rows 
between  the  stroma  fibers.  In  another  group,  also  described  as  endotheli- 
oma, the  cell  masses  are  large,  circular  on  section,  and  composed  of  large 
polyhedral,  clear  or  slightly  granular  cells. 

The  Clear  Cell  Cancer. — This  tumor  was  first  described  by  Chenot, 
in  191 1.  More  recently,  Horand  and  Fayol  have  described  a  case  arising  in 
an  accessory  ovary.  It  is  also  an  alveolar  cancer. 

The  connective  tissue  fibers  which  separate  the  alveoli  are  thin  and 
delicate  and  from  them  are  given  off  very  fine  fibrils  which  extend  into  the 
alveoli  and  envelop  the  cells  with  a  very  fine  reticulum. 

The  alveoli  are  composed  of  cells  which  are  very  different  from  the 
ordinary  typical  carcinoma  cell.  They  are  large  and  irregularly  polygonal. 
The  nucleus  is  central,  round  or  oval,  sometimes  kidney-shaped,  vesicular 


TUMORS    OF    THE    OVARY  349 

and  clear.  The  chromatin  filament  is  very  delicate  with  small,  well-stained 
nodules  which  give  it  a  finely  punctuate  appearance.  The  protoplasm  is 
extremely  clear  and  shows  a  zone  of  condensation  just  next  to  the  nucleus 
in  which  are  one  or  two  deeply  stained  centrosomes.  The  protoplasm 
appears  reticulated  with  clear  vacuoles  which  contain  glycogen.  The  limit- 
ing membrane  is  well  marked. 

Chenot  considered  his  growth  identical  in  type  and  histogenesis  with  the 
testicular  tumors  described  by  Chevassu  as  "seminomata,"  and  believes  that 
both  are  derived  from  the  germinal  epithelium.  He  considers  their  morpho- 
logic and  staining  similarities  absolutely  identical.  Massabuau  and  Etienne, 
however,  find  certain  differences  in  the  morphology  and  call  attention  to  the 
fact  that  such  clear-celled  cancers  are  not  found  exclusively  in  the  ovary  or 
testicle,  and  hence  are  not  necessarily  derivatives  of  germinal  epithelium. 
They  describe  similar  tumors  in  the  kidneys  and  mammary  glands  and 
ascribe  the  clear  appearance  of  the  cell  to  some  chemical  change  and 
especially  to  a  large  amount  of  glycogen. 

Carcinoma  Resembling  Lymphosarcoma. — There  is  a  solid  ovarian 
carcinoma  which  presents  a  diffuse  growth  of  small  round  cells  and  re- 
sembles lymphosarcoma.  It  occurs  in  young  subjects,  is  bilateral,  of  rapid 
growth,  and  produces  widespread  local  extensions  and  numerous  bulky 
metastases.  Stone's  case  presented  metastases  from  the  breast. 

Krukenberg  Tumor. — This  interesting  tumor  was  first  described  by 
Krukenberg  in  1896.  He  reported  4  cases  and  collected  from  the  previous 
literature  a  number  of  similar  cases  which  had  been  described  under  various 
names.  The  tumor  has  fairly  definite  characteristics.  It  was  bilateral 
in  39  of  43  cases  collected  by  Major  in  which  the  data  was  complete.  The 
age  varies.  Chapman,  in  1920,  observed  the  growth  in  a  girl  of  fourteen. 
The  average  age  of  Major's  series  was  thirty-six  years.  The  tumor  develops 
slowly  and  is  accompanied  by  ascites,  often  chylous  in  nature.  It 
usually  preserves  the  outline  of  the  ovary,  although  the  surface  may  be 
nodular,  and  is  firm  in  consistency,  especially  in  the  periphery.  The 
center  often  presents  soft,  myxomatous  areas.  There  may  be  large  areas 
of  cystic  degeneration  and,  occasionally,  small  cysts  lined  with  epithelium 
which  appear  like  dilated  follicles.  The  firm  part  of  the  tumor  consists  of 
spindle-shaped  cells,  suggesting  proliferated  ovarian  stroma.  In  the  myx- 
omatous areas,  the  cells  are  large  and  round,  appear  swollen  by  mucoid 
degeneration  with  a  nucleus  pushed  to  one  side  in  the  very  boundary  of  its 
capsule. 

These  tumors  often  remain  stationary  for  a  long  time  but  tend  to  spread 
through  the  lymph  channels,  at  first  within  the  ovary,  later  into  the  broad 
ligament  and  tube,  and,  occasionally,  to  give  widespread  metastases  through 
the  body.  Death  resulted  in  all  of  the  cases  of  Major's  series  in  which  the 
outcome  was  known. 

The  cells  filling  the  lymph  vessels  are  markedly  swollen  and  may  occlude 
the  lumen.  Krukenberg  believed  that  they  were  degenerated  stroma  cells, 


350 


PELVIC  NEOPLASMS 


because  he  could  not  demonstrate  a  connection  between  them  and  any  of  the 
epithelial  elements  of  the  ovary.  They  present  like  mucous  cells.  He  called 
the  tumor  fibrosarcoma  mucocellulare  carcinomatodes. 

The  growth  was  believed  by  Krukenberg  to  be  primarily  of  ovarian 
origin,  yet  it  is  now  known  that  it  is  usually  secondary  to  stomach  car- 
cinoma. It  is  well  known  that  ovarian  tumors  which  arise  secondarily  from 
primary  carcinoma  within  the  abdomen  attain  such  size  that  presently  they 
control  the  clinical  picture.  Schlagenhaufer,  in  1902,  added  4  cases  and 
Major,  in  1918,  collected  55  cases  as  well  as  8  others  which  he  felt  should 
be  included  in  the  group.  Whether  the  tumor  may  ever  be  primary  is  still 
a  matter  of  discussion.  Major  found  5  cases  in  which  no  primary  tumor  of 
the  stomach  or  intestines  was  observed  at  autopsy  (cases  of  Krukenberg, 
Glockner,  Schenk,  von  Rosthorn,  and  Sternberg). 

Metastatic  Carcinoma. — Until  quite  recently,  the  ovary  was  sup- 
posed to  accord  with  Virchow's  diction  that  organs  which  showed  a  decided 
tendency  to  primary  tumor  formation  rarely  were  the  seat  of  metastatic 
growths.  Rokitansky  and  Billroth  described  metastatic  ovarian  tumors  but 
considered  that  they  were  very  rare.  Others,  as  Pfannenstiel,  thought  that 
ovarian  carcinomata,  when  present  with  cancers  of  the  gastro-intestinal 
tract,  were  in  reality  independent  primary  tumors.  The  first  decided 
advance  came  when  Bucher  collected  9  cases  of  ovarian  cancer,  4  of  which 
were  associated  with  carcinoma  of  the  stomach,  and  5  with  carcinoma  of  the 
breast.  Bucher  regarded  the  ovarian  tumor  as  a  secondary  growth  in  all 
instances.  Similar  case  reports  presently  appeared  in  the  literature  by 
Walter,  Bode,  Fleischmann,  and  others,  so  that  Gebhard  stated  in  his  text 
that  metastatic  ovarian  carcinoma  was  probably  more  frequent  than  had 
previously  been  recognized.  Heinrichs  emphasized  the  need  of  carefully 
exploring  the  entire  abdomen  when  operating  for  ovarian  tumors  to  dimin- 
ish the  chance  of  overlooking  a  primary  growth. 

Schlagenhaufer,  in  1902,  was  the  first  to  make  a  careful  review  of  the 
literature  from  which  he  collected  79  cases,  including  8  of  his  own.  The 
ovary  was  associated  with  stomach  tumors  in  61  cases,  the  intestinal  tract  in 
10,  the  bile  tract  in  7,  and  the  supra-adrenal  gland  in  i.  Schlagenhaufer 
thought  that  all  of  the  primary  growths  were  carcinomata,  although  some 
had  been  reported  as  atypical  cancers.  The  ovarian  growths  were  variously 
diagnosed  as  carcinoma,  endothelioma,  sarcocarcinoma,  adenoma,  Kruken- 
berg tumor,  myofibroma,  etc.,  although  they  reproduced  more  or  less  closely 
the  type  of  tumor  in  the  other  part  of  the  abdomen,  with  such  variations  as 
could  be  accounted  for  by  the  difference  in  the  host.  He  thought  that  many 
of  the  ovarian  growths  reported  as  endothelioma  and  sarcoma  were  in 
reality  metastases  from  scirrhous  gastric  carcinoma.  While  the  subject  has 
not  been  finally  settled,  it  seems  likely  that  so  great  an  association  of  primary 
tumors  in  the  abdomen  would  be  at  least  most  unusual.  Gastric  carcinoma 
is  usually  primary;  very  rarely  secondary.  The  fact  that  the  ovarian  can- 
cers in  Schlagenhaufer' s  review  were  nearly  always  bilateral,  and  occurred 


TUMORS    OF    THE    OVARY  351 

in  women  whose  ovaries  were  still  functioning,  seems  to  indicate  that  these 
growths  may  well  be  secondary. 

The  metastases  frequently  dominate  the  clinical  picture.  The  gastric 
carcinoma  may  be  latent  and,  even  when  suspected,  may  not  be  found  until 
post  mortem.  In  many  of  the  cases  collected  by  Schlagenhaufer,  insufficient 
attention  was  paid  to  definite  gastro-intestinal  symptoms  before  operation. 
In  only  5  of  the  79  cases  was  the  primary  operation  directed  toward  the 
upper  abdominal  tumor.  Bland  Sutton,  later,  found  ovarian  carcinoma  in 
10  per  cent  of  autopsy  cases  with  mammary  or  gastric  carcinoma.  Other 
series  have  been  reported  by  Glockner,  Stickel,  Engelhorn,  Amann,  and 
Goulliond. 

The  association  of  mammary  and  ovarian  cancer  has  received  less  atten- 
tion. Coupland,  in  1876,  found  ovarian  metastases  in  6  per  cent  of  80 
mammary  carcinoma  and  Toerek  and  Wittelshofer  found  them  in  7  per  cent 
of  366  cases.  Handley  has  studied  422  mammary  cancers  which  he  divided 
into  two  classes,  according  as  they  died  late  in  the  disease,  or  earlier  from 
more  or  less  accidental  causes.  Ovarian  metastases  were  found  in  8.6  per 
cent  of  the  former,  and  in  only  4.8  per  cent  in  the  latter  group. 

Stone,  in  1916,  reviewed  the  subject  of  ovarian  metastases  and  added 
133  cases  from  the  literature  to  the  79  cases  collected  by  Schlagenhaufer. 
The  primary  tumor  was  found  in  the  stomach  in  75  cases,  in  the  breast  in 
25,  in  the  large  intestine  in  22,  in  the  gall-bladder  or  ducts  in  5,  in  the 
small  intestine  4,  and  i  in  the  pancreas  and  i  in  the  appendix. 

Amann,  from  a  study  of  1 8  of  his  owTn  cases,  and  a  review  of  the  liter- 
ature, believes  that  secondary  ovarian  carcinoma  may  be  grouped  into  three 
histological  types:  (i)  the  edematous  fibroma,  with  epithelial  infiltrations 
which  may  show  colloid  degeneration;  (2)  the  nodular  medullary  car- 
cinoma; and  (3)  the  cystoma  with  areas  of  fibrocarcinoma. 

Amann's  first  group  suggests  that  the  ovarian  connective  tissue  hyper- 
trophies tremendously  as  a  characteristic  reaction  to  the  invasion  of  neo- 
plastic  elements,  since  the  epithelial  alveoli  are  usually  very  scanty.  There 
is  usually  marked  edema,  or  cyst  formation,  in  the  central  parts  of  the 
tumors.  Hemorrhagic  areas  are  frequent.  The  epithelial  elements  show 
colloid  degeneration  and  sometimes  present  as  typical  colloid  carcinoma 
similar  to  that  seen  in  the  gastro-intestinal  tract.  As  has  been  already  indi- 
cated, there  is  very  strong  feeling  that  the  Krukenberg  tumor  really  belongs 
in  this  group.  Four  of  Amann's  cases  were  Krukenberg's  tumors,  as  were  4 
of  Schlagenhaufer's  79  cases,  4  of  Stauder's  60  cases,  2  of  Glockner's  15, 
and  i  each  of  Wagner's  and  Schenk's.  Primary  gastro-intestinal  cancers 
were  demonstrated  in  nearly  all  of  the  63  Krukenberg's  tumors  reported  by 
Major  in  1918.  The  fact  remains,  however,  that  there  are  5  cases  of 
Krukenberg  tumors  in  which  careful  post-mortem  examination  failed  to 
demonstrate  primary  tumors  of  the  stomach  or  intestine.  Others  of 
Amann's  first  group  of  tumors  presented  a  histologic  structure  rather  similar 
to  endothelioma  or  sarcoma. 


352  PELVIC   NEOPLASMS 

Cyst  formation  is  frequently  found  in  the  second  group  of  solid  nodular 
adenocarcinoma  in  contrast  to  the  third  type  which  are  true  cystoma  with 
fibro-adenomatous  and  carcinomatous  alveoli.  Edema  is  a  common  finding 
in  all  of  the  tumor  groups. 

ROUTE  OF  METASTASES. — Various  methods  of  extension  appear  possible. 
Thus  the  cells  may  be  transported  by  lymph  or  blood  stream  or  by  direct 
implantation  of  tumor  particles  through  the  peritoneal  cavity. 

The  last  view  is  accepted  by  the  majority  of  more  recent  authorities 
who  believe  that  the  primary  tumor  early  penetrates  the  serosa  in  a  micro- 
scopic manner.  The  general  peritoneum  does  not  share  in  the  involvement, 
possibly,  as  Krauss  urges,  because  the  germinal  epithelium  is  more  per- 
meable than  the  peritoneum,  a  conclusion  which  is  not  acceptable  to  Wolff- 
heim.  This  author  believes  the  ovary  is  most  susceptible,  because  of  the 
injury  to  its  surface  resulting  from  rupture  of  the  graafian  follicles.  The 
fact  that  the  ovary  often  lies  in  the  pouch  of  Douglas  is  believed  by  many  to 
favor  peritoneal  implantation. 

Metastases  by  way  of  the  blood  stream  probably  occur  only  in  excep- 
tional cases. 

Mammary  carcinoma,  according  to  Handley,  spread  by  the  lymphatics 
through  the  deep  fascial  plexus  to  the  epigastric  triangle,  when  the  cancer 
cells  invade  the  peritoneal  cavity  and  follow  the  same  metastatic  routes  as 
the  intra-abdominal  carcinoma. 

The  metastases  may  be  transported  through  the  lymphatics  directly  or  by 
a  retrograde  process.  Direct  extensions  probably  occur  only  when  the 
primary  tumor  is  in  neighboring  organs,  as  the  rectum  or  sigmoid.  Roemer, 
Glockner,  Stickel,  Pfannenstiel,  and  others,  believe  that  the  majority  of 
cases  result  from  retrograde  lymphatic  transportation.  They  state  that 
the  invasion  extends  through  the  lymph  vessels  and  nodes  behind  the  stom- 
ach and  pancreas  into  the  retroperitoneal  lymphatics  which  lie  on  both  sides 
of  the  aorta,  to  the  enlarged  lumbar  nodes,  from  which  the  cells  are  trans- 
ported into  the  ovaries  through  the  hilum  by  a  reverse  current  in  the  lymph 
vessels  along  the  ovarian  artery  and  vein.  Oscar  Frankl  has  recently  sup- 
ported this  theory  in  an  extensive  paper.  He  calls  attention  to  the  fact 
that  there  is  associated  with  a  very  large  proportion  of  metastatic  ovarian 
carcinoma  a  microscopic  invasion  of  the  lymphatics  of  the  uterus  and  tube. 
This  is  found  in  the  musculature  or  mucosa  but  rarely  on  the  peritoneal  sur- 
face. Primary  ovarian  carcinoma,  on  the  other  hand,  frequently  shows 
peritoneal  implantations  on  the  surface  when  it  metastasizes  to  the  uterus, 
yet  a  microscopic  involvement  of  the  lymphatics  is  not  seen. 

CLINICAL  FEATURES  OF  OVARIAN  CANCER 

Stages  of  Growth. — Ovarian  cancer  may  present  three  stages  of 
growth,  local,  regional  and  general.  The  first  stage  is  marked  by  enlarge- 
ment and  rapid  destruction  of  the  ovary.  The  steps  may  not  be  clearly 


353 

defined,  however,  even  in  the  very  earl)'  stages,  since  many  tumors  originate 
from  surface  germinal  epithelium  when  there  is, 'at  the  same  time,  local  and 
regional  growth.  When  the  tumor  remains  encapsulated,  there  may  be  very 
little  normal  ovarian  tissue  at  the  end  of  the  first  stage.  Only  one  of 
Massabuau  and  Etienne's  series  of  250  cases  presented  any  normal 
structures. 

The  second  stage  is  marked  by  invasion  of  the  regional  lymph  glands 
and  the  neighboring  organs.  The  opposite  ovary  usually  is  the  first  organ 
involved.  Early  extensions  probably  occur  by  direct  invasion  through  the 
peritoneal  cavity  accompanied  in  their  latter  stages  by  lymphatic  involve- 
ment. Peritoneal  implantations  may  be  observed  in  the  latter  part  of  this 
stage  on  the  large  and  small  intestine  and  in  the  pouch  of  Douglas.  They 
may  be  noted  in  cases  which  do  not  present  adhesions,  although  this  com- 
plication is  more  usual.  The  adhesions  may  be  of  inflammatory  or  neo- 
plastic  origin. 

The  third  stage  is  marked  by  a  generalization  of  the  carcinomatous 
process  throughout  the  body.  The  invasion  results  from  extension  into  the 
blood  vessels.  True  peritoneal  carcinosis  is  often  noted. 

Involvement  of  Lymph  Glands. — The  lymph  glands  are  usually 
involved  by  the  time  the  case  comes  to  operation.  They  are  invariably 
involved  in  the  late  cases.  In  7  of  Massabuau  and  Etienne's  cases  in  which 
a  complete  postmortem  examination  was  made,  the  lumbar  glands  were 
involved  in  5  cases,  in  i  of  which  one  side  only  was  affected.  The  internal 
iliac  glands  were  twice  involved  and  the  mesenteric  glands  in  a  similar 
number.  The  subrenal  and  bronchial  glands  showed  carcinomatous  changes 
in  i  case  in  which  the  disease  was  generalized.  The  mesenteric  glands  may 
be  invaded  by  retrograde  metastasis  or  secondarily  from  peritoneal  im- 
plantations on  the  intestinal  wall. 

The  ovarian  lymphatics  merit  description.  They  begin  as  a  capillary 
network  about  the  follicles  and  drain  into  five  or  six  trunks  which  follow 
the  blood  vessels,  passing  in  front  of  the  ureter  to  empty  on  the  left  side 
into  a  group  of  two  or  three  glands  lying  in  front  of  the  aorta,  and  a  little 
below  the  hilum  of  the  kidney.  The  glands  on  the  right  side  lie  a  little 
lower  down  and  upon  the  vena  cava.  The  larger  lymphatics  contain  few 
valves  and  allow  a  retrograde  circulation.  There  are  a  few  small  accessory 
glands  along  the  course  of  the  ovarian  vessels.  The  ovarian  lymphatics  do 
not  form  a  closed  system  but  anastomose  freely  with  those  of  the  uterus 
and  vagina  and  thus  come  into  relation  with  the  hypogastric,  external  iliac 
and  even  with  the  crural  glands. 

Involvement  of  Neighboring  Organs. — The  tube  of  the  affected 
side  early  shows  inflammatory  changes  and  later  is  invaded  by  the 
cancer.  The  adnexa  of  the  opposite  side  soon  become  involved  and  present 
the  same  appearance  as  the  primary  growth.  Even  though  they  appear 
normal  macroscopically,  foci  of  the  disease  may  be  demonstrated  with  a 
microscope.  The  uterus  may  show  mechanical,  inflammatory,  or  neoplastic 


354  PELVIC  NEOPLASMS 

changes.  Primary  ovarian  carcinoma  do  not  give  rise  to  uterine  metastases 
-in  their  early  stages,  although  the  ovary  is  early  invaded  by  extensions  from 
uterine  cancers.  Massabuau  and  Etienne  found  uterine  metastases  in  only 
2  of  their  250  cases.  The  broad  ligament  is  not  usually  involved,  nor  is  the 
vagina,  except  in  the  very  late  cases.  Omental  metastases  are  common,  as 
are  regional  peritoneal  implantations. 

The  bladder  is  not  often  invaded,  although  it  may  be  displaced  or 
adherent.  Massabuau  and  Etienne  could  not  demonstrate  carcinomatous 
infiltration  in  the  ureter  of  any  of  their  cases,  even  though  the  kidney  in  one 
case  showed  extensive  disease.  Metastases  may  be  found  in  the  kidneys, 
liver,  lungs,  pleura,  and  very  rarely  in  the  spleen  and  heart. 

Symptoms. — The  symptomatology  varies.  Occasionally  there  may 
be  no  symptoms.  The  tumor  was  accidentally  discovered  in  16  cases  in 
the  Massabuau  and  Etienne  series.  Patients  presenting  early  growths 
may  complain  of  pain,  menstrual  disturbances,  or  increase  in  the  size 
of  the  abdomen,  or  very  rarely  disturbances  in  the  general  health. 

Pain  is  the  most  frequent  initial  symptom  and  may  develop  insidiously 
and  gradually  increase,  or  may  appear  with  the  suddenness  of  an  acute 
abdominal  crisis.  It  occurs  with  equal  frequency  in  the  very  young  and 
the  aged.  It  is  usually  in  the  ovarian  region  and  may  be  accompanied  by 
pain  which  radiates  to  the  iliac  fossa  or  down  the  leg.  Occasionally 
it  is  only  backache  which  radiates  to  the  groins.  Often  it  is  merely  a 
sense  of  heaviness,  yet  it  may  be  lancinating  and  severe. 

The  menstrual  disturbances  may  consist  of  amenorrhea,  irregu- 
larity, or  menorrhagia.  Massabuau  and  Etienne  found  that  suppres- 
sion of  the  menses  constituted  the  first  symptom  in  8  cases,  in  2  of 
which  it  ceased  abruptly.  Irregularity  is  more  common  and  may  pre- 
cede either  amenorrhea  or  metrorrhagia.  Menorrhagia  alone  rarely 
marks  the  onset  of  symptoms.  Metrorrhagia  is  far  more  common  and 
may  present  in  women  past  the  menopause  without  premonitory 
symptoms. 

Increase  in  size  of  the  abdomen  is  usually  due  to  ascites,  since  the 
tumor  itself  plays  a  secondary  role.  Ascites  may  be  present  even  when 
cancerous  involvement  of  the  peritoneum  cannot  be  demonstrated.  It 
was  present  in  35  of  the  41  cases  in  which  the  condition  of  the  abdo- 
men was  recorded  in  Massabuau  and  Etienne's  series,  and  absent  in  6. 
The  increase  in  size  of  the  abdomen  constituted  the  first  symptom  in 
28  cases. 

Disturbances  in  the  general  health,  digestive  upsets,  or  urinary 
symptoms  occasionally  may  constitute  the  first  symptoms  of  the 
disease. 

The  initial  symptoms  do  not  long  remain  as  the  sole  complaint. 
The  patient  looks  sick,  becomes  emaciated,  has  cessation  of  menstrua- 
tion, and  complains  of  vomiting  and  pain.  Constipation  may  be  ex- 
tremely obstinate.  Menses  cease  invariably  when  both  ovaries  become 


TUMORS    OF    THE    OVARY  355 

involved.  The  urinary  symptoms  include  polyuria,  imperative  mictu- 
rition, slight  incontinence  and  dysuria.  There  is  usually  edema  of  the 
legs  and  back  and  dyspnea  in  the  stage  of  cachexia.  Some  patients 
have  a  tendency  to  somnolence. 

Complications. — Complications  are  rather  rare.  Torsion  of  the 
pedicle  is  not  often  seen.  Occasionally,  ascites  may  be  sufficient  to 
cause  pressure  symptoms  and  dyspnea.  The  fluid  soon  recurs  after 
tapping.  Intestinal  obstruction  is  not  unusual  in  the  terminal  condi- 
tion when  phlebitis  may  also  be  present.  There  may  be  anuria. 

Pregnancy  occasionally  forms  a  complication  and  abortions  some- 
times result.  Dystocia  may  occur  if  the  tumor  becomes  jammed  down 
in  the  pelvis  in  advance  of  the  fetal  head.  The  growth  increases 
rapidly  during  the  pregnancy  because  of  the  increased  vascularity  of 
the  pelvic  structures. 

Diagnosis. — The  diagnosis  is  not  often  made  in  early  cases,  since 
there  are  rarely  findings  other  than  the  presence  of  an  ovarian 
tumor.  Bilateral  growths  accompanied  by  gastric  disturbances  should 
arouse  the  suspicion  that  the  condition  is  metastatic.  Yet  visceral  neo- 
plasms develop  frequently  without  marked  symptoms,  and  the  great 
majority  of  bilateral  ovarian  tumors  are  papillary  cystadenomata.  In 
the  later  stages,  the  diagnosis  is  more  simple  because  of  the  presence  of 
definite  symptoms  of  malignancy.  Yet  the  clinical  diagnosis  is  often 
incorrect.  There  is  marked  ascites,  loss  of  weight,  symptoms  of  intes- 
tinal obstruction  and  the  presence  of  a  more  or  less  fixed  tumor.  Even 
a  histologic  diagnosis  may  be  made  occasionally  only  with  difficulty. 

Treatment. — The  treatment  is  removal  of  both  ovaries,  together 
with  the  uterus.  Theoretically  logical,  it  may  be  difficult  of  accom- 
plishment. The  presence  of  adhesions  and  metastases  may  complicate 
the  operation.  In  marked  contrast  to  uterine  cancers,  operation  may 
be  attempted  even  in  late  cases  of  ovarian  malignancy,  since  the  mere 
size  of  the  tumor  may  give  rise  to  symptoms.  Both  ovaries  should  be 
removed  because  of  the  frequency  with  which  cancerous  deposits  are 
found  microscopically  in  ovaries  which  appear  normal  on  casual  in- 
spection. The  uterus  should  be  removed,  since  it  adds  to  the  chance 
of  cure.  Several  investigators  have  developed  upon  the  cadaver  a 
method  of  removing  the  lumbar  glands,  yet  this  procedure  cannot  be 
advised  at  present,  since  it  may  not  prove  necessary  in  early  cases  and 
will  not  aid  in  the  later  ones.  Implantations  upon  the  viscera  should 
be  removed  when  they  are  distinctly  local.  If,  however,  the  glands 
are  involved,  the  procedure  will  be  valueless.  Before  attempting  the 
removal  of  ovarian  cancer,  the  upper  abdomen  should  be  thoroughly 
explored  to  determine  whether  there  is  another  malignant  tumor.  This 
should  be  treated,  if  present,  as  the  conditions  warrant,  yet  the  removal 
of  secondary  ovarian  tumors  may  be  warranted  if  they  dominate  the 


356  PELVIC  NEOPLASMS 

clinical    picture.      Frankl    advises    post-operative    Roentgenotherapy. 
Secondary  operations  for  metastases  may  prolong  life  occasionally. 

Prognosis. — The  literature  shows  that  operations  have  been  at- 
tended with  considerable  mortality.  Massabuau  and  Etienne  found 
an  immediate  mortality  of  24  per  cent  in  49  cases  of  simple  oopho- 
rectomy,  22  per  cent  in  27  cases  of  bilateral  oophorectomy,  and  9  per 
cent  in  22  cases  of  hysterectomy  with  bilateral  oophorectomy.  While 
this  represents  the  mortality  of  an  earlier  surgical  period,  it  stands  to 
reason  that  there  will  always  be  definite  mortality  when  patients  weak- 
ened by  ovarian  cancer  undergo  extensive  operative  procedures.  Shock 
is  extremely  likely.  Adhesions  to  the  small  intestines  may  demand 
intestinal  resection  in  rare  cases  and  adds  to  the  mortality. 

Of  89  operative  recoveries,  Massabuau  and  Etienne  found  that  59  had 
been  followed.  Of  these,  48  died  of  recurrence  and  n  survived,  7  for 
more  than  four  years.  The  value  of  the  statistics  is  impaired  by  the 
fact  that  the  cases  were  variously  treated,  some  by  simple  oophorec- 
tomy and  others  by  double  oophorectomy,  with  and  without  the  re- 
moval of  the  uterus.  The  tumor  may  recur  after  operation  in  the  form 
of  papillary  nodules  about  the  stump,  in  the  abdominal  wound,  or  on 
the  peritoneum.  The  recurrence  may  not  be  suspected  for  some  time 
after  removal  of  the  original  tumor,  even  as  long  as  two  years.  The 
majority  of  recurrences  follow  the  removal  of  intraligamentous 
growths  which  have  presented  technical  difficulties.  Recurrences  have 
been  observed  as  late  as  twelve  years.  These  figures  supplant  the  older 
report  of  Pfannenstiel.  He  stated  that  there  were  83.3  per  cent  re- 
currences in  papillary  carcinoma  which  had  been  followed  for  four 
years  as  contrasted  with  66  per  cent  for  the  other  types  of  ovarian 
cancers  which  had  been  under  observation  for  a  similar  period.  There 
are  no  other  series  of  size  from  which  we  may  draw  conclusions,  yet, 
since  recurrences  have  been  recorded  between  six  weeks  and  eight 
years,  it  is  difficult  to  speak  of  true  cures.  The  survival  following 
recurrence  is  usually  very  short.  The  patient  succumbs  to  cachexia, 
and  rarely  lives  longer  than  six  months. 

EMBRYOMA 

This  includes  dermoids  and  the  teratoma,  both  of  which  arise  from 
germ  cell  elements  and  contain  all  three  germinal  layers.  The  der- 
moids are  essentially  benign  tumors,  composed  of  adult  tissues  ar- 
ranged in  a  more  or  less  orderly  manner  to  represent  rudimentary 
organs.  The  teratoma,  on  the  contrary,  are  malignant  tumors  com- 
posed of  embryonic  cells  which  are  mingled  indiscriminately  without 
tendency  to  orderly  arrangement.  There  are  numerous  transition 
forms  which  occur  between  the  two  types  of  tumors,  thus  building  up 
an  almost  continuous  series. 


TUMORS     OF     THE     OVARY  357 

Etiology. — Since  the  same  views  for  the  etiology  are  advanced  for 
both  tumors,  we  will  consider  them  before  taking  up  their  clinical  mani- 
festations. Two  views  are  now  advocated:  (i)  that  they  develop  from 
an  unfertilized  ovum;  and  (2)  from  an  isolated  somatic  blastomere, 
which  by  some  irregularity  of  development  has  been  included  in  the 
ovary.  The  theory  that  they  develop  from  mature  ova  which  were 
impregnated  before  they  left  the  graafian  follicle  no  longer  holds.  Such 
a  phenomenon  would  result  in  ovarian  gestation  rather  than  a  tera- 
toma.  It  would  not  explain  the  tumor  in  unborn  fetuses  and  infants. 
Tumors  at  this  age  cannot  be  explained  by  the  theory  of  Shattuck, 
who  held  that  a  surplus  spermatazoon  remained  about  the  segmenting 
morula  and  was  held  between  its  component  cells  to  later  fertilize  a 
primordial  ovum.  MeckeFs  view  that  embryoma  represent  the  inclu- 
sion of  one  fertilized  ovum  within  another  is  also  discarded. 

There  are  objections  to  both  of  the  prevailing  theories.  Opitz  and 
Menge  state  that  it.  is  unreasonable  to  believe  that  they  arise  from 
unfertilized  ova,  since  they  may  occur  in  parts  of  the  body  far  distant 
from  the  ovary,  may  occur  in  men,  and  even  in  the  testis.  They  state, 
moreover,  that  they  would  be  found  more  frequently  in  the  tube, 
since  unfertilized  eggs  pass  through  that  structure  in  tremendous  num- 
ber, yet  only  5  authentic  cases  in  that  location  have  been  reported.  On 
the  contrary,  Pfannenstiel  supports  the  view,  arguing  that  the  neo- 
plasm develops  from  a  totipotent  cell  and  rarely  occurs  before  puberty 
and  practically  never  after  the  menopause. 

The  theory  that  they  arise  from  blastomeres  is  receiving  much  sup- 
port. Marchand  and  Bonnet  are  recent  advocates.  The  theory  holds 
that  the  earliest  segmentation  divides  the  ovum  into  two  kinds  of 
blastomeres,  one  type  of  which  become  germ  cells  and  the  other, 
somatic  cells  which  enter  into  the  construction  of  the  body.  The 
blastomeres,  therefore,  are  the  products  of  the  first-cell  division  of  the 
impregnated  egg.  In  the  complicated  process  of  growth  in  the  early 
embryonal  period,  some  of  these  cells  may  be  displaced  in  various  parts 
of  the  developing  organism.  Somatic  blastomeres  included  in  the 
ovary  might  be  destroyed  undeveloped  or,  after  a  long  latent  period, 
might  assume  sudden  growth  and  create  a  dermoid  or  teratoma.  From 
such  cells  all  three  germinal  layers  may  arise.  Against  this  theory  it  is 
urged  that  it  does  not  seem  reasonable  that  these  cells  would  be  dis- 
placed chiefly  in  the  ovary,  from  which  organ  develop  the  great 
majority  of  tumors.  The  fact  that  many  dermoids  may  be  noted  in 
one  ovary  also  argues  against  the  theory  that  the  embryoma  arise 
from  isolated  blastomeres.  As  many  as  eleven  dermoids  have  been 
noted  in  one  ovary,  and  twenty  in  both.  It  seems  almost  impossible 
to  believe  that  they  all  could  be  explained  on  this  ground.  No  theory, 
in  consequence,  is  without  objection. 


358  PELVIC   NEOPLASMS 

Cystic  Dermoids. — Cystic  dermoids  are  more  properly  known  as 
teratomatous  cysts.  They  differ  from  dermoid  cysts  in  other  parts 
of  the  body  in  that  they  contain  all  three  germinal  layers  while  true 
dermoids  contain  only  ectodermal  structures.  The  tumors  are  cystic 
and  contain  products  of  the  skin  glands  which,  while  fluid  at  the  body 
temperature,  are  thick  and  doughy  when  cooled.  The  growths  consist 
of  two  parts:  (i)  an  embryonal  rudiment  in  which  can  be  demonstrated 
tissues  derived  from  all  three  layers  of  the  blastoderm;  and  (2)  the 
cyst  into  which  the  rudiment  is  growing. 

Frequency. — The  frequency  is  variously  stated.  Spencer  Wells 
reported  2.2  per  cent  in  his  series  of  1,000  ovarian  tumors,  yet  his  cases 
were  seen  only  when  ovarian  tumors  were  considered  operative,  and 
dermoids  rarely  attained  great  size.  Olshausen  found  a  frequency  of 
4  per  cent  in  2,275  ovarian  tumors.  Later  authors  found  higher  per- 
centages. Dermoids  formed  18.8  per  cent  of  138  of  Howard  Kelly's 
ovarian  tumors,  and  18.7  per  cent  of  64  cases  reported  by  Sanger. 
There  were  98  dermoids  in  1,000  ovarian  tumors  removed  by  the 
Mayos  during  1905-1912. 

Age. — Dermoids  have  been  observed  at  all  ages  from  fetal  life 
to  extreme  old  age.  They  are  very  uncommon  except  during  sexual 
activity.  More  occur  between  thirty  and  forty  years  than  any  other 
decade.  They  form  the  majority  of  ovarian  tumors  in  childhood  and 
about  the  period  of  puberty,  yet  they  are,  nevertheless,  rare  at  that 
time.  Tumors  which  are  first  seen  after  the  menopause  are  apt  to 
show  malignant  degeneration. 

Appearance  and  Form. — They  form  smooth  growths,  of  spherical 
shape,  except  when  they  co-exist  with  cystadenomata  when  their  form 
is  irregular.  They  vary  in  size  from  a  cherry  seed  to  that  of  a  man's 
head.  The  majority  seldom  exceed  6  or  7  centimeters  in  diameter. 
A  few  large  tumors  have  been  reported.  Keith,  in  1895,  reported  one 
weighing  one  hundred  pounds,  associated  with  a  small  dermoid  on  the 
opposite  side.  Byford,  in  1898,  described  one  weighing  seventy 
pounds  which  he  removed  from  a  patient  of  fifty-two  years  who  had 
first  noticed  enlargement  of  the  abdomen  twenty-five  years  previously. 

Dermoids  are  usually  unilateral  but  may  affect  both  ovaries.  Man- 
tel, in  reviewing  191  cases,  found  26  that  were  bilateral.  Gebhard,  in 
107  cases,  found  16  bilateral.  There  were  14  bilateral  dermoids  in  the 
Mayos'  98  cases.  Manton,  who  reviewed  the  literature  for  a  ten-year 
period  a  few  years  ago,  found  330  dermoids  reported  during  that  time. 
Forty-six  were  bilateral.  Hines  found  that  only  309  bilateral  dermoids 
of  the  ovary  had  been  reported  in  the  literature  for  the  past  one  hun- 
dred years;  of  these,  90  were  collected  by  himself,  not  having  been 
included  in  the  219  cases  compiled  by  others. 

Dermoids  usually  possess  a  long  pedicle  which  permits  them  to 
rise  into  the  abdominal  cavity  at  a  fairly  early  period.  Intraliga- 


TUMORS    OF    THE    OVARY  359 

mentous  development  is  rare  (6  per  cent  of  cases  according  to  Lip- 
pert).  Very  occasionally,  ovarian  dermoids  may  be  retroperitonal. 
Bardenheuer  and  Zweifel  have  described  dermoids  in  the  loins  which 
they  thought  developed  from  rests  left  in  the  descent  of  the  ovaries. 
Dermoids  in  these  unusual  situations  must  be  distinguished  from 
dermoids  of  the  pelvic  connective  tissue  described  by  Sanger.  The 
presence  of  ovarian  substance  is  conclusive. 

The  tumors  may  replace  the  whole  ovary,  although  ovarian  tissue 
usually  remains  as  a  nodular  thickening  of  the  wall.  The  presence 
of  corpora  lutea  shows  that  this  tissue  is  functioning.  Therefore, 
sterility  is  not  a  necessary  result  even  in  bilateral  tumors.  Manton 
recently  collected  19  cases  of  pregnancy  associated  with  bilateral  der- 
moids. Dermoids  may  arise  from  accessory  ovaries,  as  is  shown  by 
the  fact  that  the  normal  ovaries  are  unaltered.  The  tumor  occasionally 
projects  from  an  apparently  normal  ovary,  suspended  from  it  by  a  defi- 
nite pedicle.  In  case  the  pedicle  becomes  severed,  either  from  torsion 
or  the  pull  of  adhesions,  the  tumor  may  attach  itself  to  the  omentum 
or  mesentery. 

The  cysts  are  usually  unilocular.  Their  contents  vary.  Their 
character  is  profoundly  affected  by  torsion  of  the  pedicle.  Both  the 
dermoids  and  solid  teratoma  are  frequently  seen  with  ovarian  cystoma ; 
Arnspenger  noted  the  association  in  14  per  cent  of  cases.  They  are 
most  often  found  with  the  pseudomucinous  type  when  they  are  likely 
to  break  through  the  septa  and  occupy  the  center  of  the  tumor.  They 
may  occur  with  simple  serous  cysts,  papillary  growths  and  corpus 
luteum  cysts. 

Structure. — In  contrast  with  the  true  dermoids  of  other  portions 
of  the  body,  ovarian  dermoids  are  rarely  lined  with  skin.  This  struc- 
ture is  confined  to  the  embryonal  rudiment,  or  to  its  immediate  neigh- 
borhood. The  peripheral  cyst  wall  which  does  not  belong  to  the  actual 
dermoid  anlage  consists  of  several  parallel  layers  of  connective  tissue 
usually  loose  in  structure.  The  inner  layer  is  rich  in  vessels.  The 
remains  of  the  ovarian  substance  lie  in  the  outer  layer.  The  inner 
surface  of  the  cyst  is  at  first  covered  with  a  low  stratified  or  cubical 
epithelium,  occasionally  suggesting  amnion.  Later,  this  epithelium 
is  destroyed,  because  of  irritation  by  the  hair  and  by  the  secretion  from 
the  skin  glands  of  the  embryoma  and  is  replaced  by  reddish  brown 
layers  of  granulation  tissue  containing  numerous  giant  cells  where  the 
hair  shafts  cut  in,  and  with  infiltration  from  hemorrhage.  Areas  of 
calcification  may  be  seen  in  the  older  and  larger  tumors. 

A  rounded  mass  is  usually  found  projecting  from  the  wall  into  the 
cyst  cavity.  This  is  the  dermoid  plug  which  contains  in  varying  pro- 
portions structures  derived  from  all  three  embryonic  layers,  usually 
with  a  marked  preponderance  of  ectoderm  and  especially  of  the  struc- 
tures of  the  cephalic  end  of  the  body.  Wilms  considers  it  a  rudimen- 


360  PELVIC   NEOPLASMS 

tary  embryonal  formation  which  is  hindered  in  its  development  by 
the  confined  space  of  the  cyst  cavity.  Because  of  mechanical  disturb- 
ances, only  the  tissues  which  are  first  differentiated  in  the  embryo 
come  to  full  development.  Thus,  ectodermal  and  cephalic  structures 
are  more  abundant  than  those  derived  from  the  entoderm. 

The  embryoma  tends  to  follow  in  a  rudimentary  and  distorted 
manner  the  arrangement  of  the  fetal  structures.  The  thick  skin  and 
abundant  hair  represents  the  scalp.  Under  this  are  plates  of  bone 
representing  the  cranium.  A  firm  connective  tissue  corresponds  to 
the  dura,  under  which  are  representatives  of  brain  tissue.  There  are 
also  other  portions  of  skull  tissues — jawbones,  teeth,  and  epithelial 
organs  of  the  buccal  cavity.  The  respiratory  and  intestinal  tracts  are 
least  developed.  They  may  present  only  as  tubes  lined  with  cylin- 
drical or  ciliated  epithelium. 

Occasionally,  the  dermoid  plug  does  not  project  into  the  cyst  lumen. 
It  is  indicated  by  a  thickened  area  in  which  are  bunches  of  hair 
lying  flat  on  the  cyst  wall.  On  section,  however,  one  may  demonstrate 
typical  fetal  structure. 

Few  structures  of  the  body  have  not  been  represented  in  dermoid 
cysts.  The  skin  contains  sebaceous  and  sudoriferous  glands.  Even  the 
erector  muscles  of  the  hair  have  been  described.  Hair  is  constantly 
present  and  the  strands  may  be  as  long  as  a  meter.  The  color  is  usually 
reddish  brown,  although  it  may  be  anything  from  white  to  black.  The 
color  may  not  resemble  that  of  the  patient  and  may  vary  in 
the  same  cyst,  and  even  in  the  same  strand.  Sometimes  the  hair 
pierces  the  opposite  wall  of  the  cyst  and  grows  through  it  when  the 
process  is  attended  by  a  giant  cell  reaction. 

Wilms  states  that  there  are  always  tissues  of  the  central  nervous 
system,  even  in  dermoids  the  size  of  a  pea.  Occasionally,  the  structure 
may  be  differentiated  in  a  most  remarkable  manner,  yet  this  occurs 
only  in  the  larger  tumors.  Rudiments  of  eyes  are  common.  They 
may  be  accompanied  with  eyelids  and  lashes.  Rudimentary  ears  have 
also  been  found.  The  peripheral  nervous  system  is  not  as  well  developed 
as  the  central,  although  there  may  be  large  nerve  trunks  and  even 
suggestions  of  the  gasserian  ganglion.  Sympathetic  ganglia  have  also 
been  described  within  the  muscle  wall  of  the  intestinal  tract.  The 
cranial  bones  may  be  remarkably  developed.  Teeth  are  extremely 
common  and  may  be  well  developed,  although  they  usually  pre- 
sent as  rudiments.  Sometimes  large  numbers  of  teeth  are  found; 
Schnabel  reported  one  hundred  and  Ploquet  three  hundred  in  a  single 
dermoid.  Mammary  glands  have  been  described  by  Sutton,  Reverdin, 
and  von  Velits.  There  was  colostrum  in  the  case  of  the  latter. 

Derivatives  of  the  mesoderm  may  be  represented  nearly  as  well 
as  those  of  the  ectoderm.  The  arrangement  tends  to  approach  the 
normal.  Smooth  muscle  occurs  commonly,  striated  muscle  quite 


TUMORS    OF    THE    OVARY  361 

rarely.  Cartilage  is  common.  Askanazy  claims  that  fibrocartilage 
is  as  common  as  hyaline.  The  bones  may  even  contain  marrow.  Blood 
vessels  may  attain  remarkable  development.  In  one  of  Wilms'  cases, 
a  large  artery  sent  branches  to  the  buccal  cavity  and  to  the  brain 
(internal  and  external  carotid).  There  may  even  be  blood  constituents 
in  the  lymph  follicles  and  bone  marrow. 

Entodermic  structures  are  much  less  developed.  They  appear 
usually  in  most  rudimentary  form.  Thyroid  tissue  lies  by  the  side  of 
the  trachea.  It  may  even  be  recognized  macroscopically.  A  larynx 
and  vocal  cords  have  been  reported  by  Kroemer.  Other  parts  of  the 
respiratory  tract,  as  atrophic  lung  rudiments  containing  bronchi  open- 
ing into  a  rudimentary  trachea,  have  been  described  by  Wilms.  The 
respiratory  part  of  the  nose  with  a  nasal  septum  has  also  been  noted. 
The  intestinal  tract  may  be  represented  by  canals  with  typical  epithe- 
lium, intestinal  villi,  and  glands,  smooth  musculature,  solitary  lymph 
follicles,  and  Fever's  patches.  There  may  be  embryonic  stomachs, 
small  and  large  intestines.  Loops  of  intestine  with  a  mesentery  rarely 
attain  size  to  be  recognized  macroscopically.  Pommer  has  reported 
a  cecum  with  an  appendix. 

Rudiments  of  the  liver,  kidney,  and  pancreas  have  not  been  demon- 
strated. Von  Recklinghausen  found  a  structure  resembling  the  wolf- 
fian  body.  Kroemer  described  what  appeared  as  miillerian  tissue  con- 
sisting of  an  endometrium  lying  on  a  thick  layer  of  smooth  muscle  with 
cervical  stroma  and  epithelium  and  vaginal  mucosa. 

While  these  tissues  commonly  present  as  isolated  remnants,  there 
is,  in  rare  cases,  more  complete  development  of  the  embryo.  This 
occurs  in  tumors  the  size  of  a  head  or  larger  and,  according  to  Wilms, 
only  when  there  is  not  much  cyst  pressure.  Nearly  the  entire  fetal 
body  may  be  recognized  macroscopically.  Axel  Key  described  a  fetus 
attached  by  the  head,  having  a  bony  skull,  brain,  jaws,  and  two  lower 
extremities  with  toes.  There  was  hair  on  the  scalp  and  on  the  mons 
veneris.  Repin  found  a  complete  skeleton,  on  the  right  side  of  which 
was  a  complete  bony  framework,  even  including  phalanges.  Aska- 
nazy's  case  was  a  misformed  fetus  with  a  head,  having  two  hair 
bundles,  a  brain,  a  pigmented  eye  spot,  an  ear  and  body  with  two  legs 
with  toes,  and  a  pubic  region  presenting  a  rudimentary  clitoris  and 
corpora  cavernosa.  Shattuck  found  an  acardiacus  with  lower  extremi- 
ties, vulva,  pubis,  perineum,  pelvis,  vertebra,  and  a  blind  intestinal 
loop. 

No  sign  of  fetal  membranes  has  ever  been  described. 

Atypical  Forms  of  Dermoids. — These  are  also  called  biphilloma. 
They  contain  only  ectodermal  and  mesodermal  derivatives.  Kroemer 
says  they  constitute  5  per  cent  of  all  ovarian  dermoids.  Cases  have 
been  described  by  Wilms,  Kroemer,  Neck,  and  Namvenck,  Askanazy 
and  others.  The  diagnosis  can  be  made  only  by  serial  sections,  since 


362  PELVIC   NEOPLASMS 

it  depends  upon  absence  of  the  entodermic  layer.  The  case  of  Saxen, 
which  presented  a  single  tooth  in  an  otherwise  normal  ovary,  is  the 
extreme  type  of  this  condition.  Some,  as  Hanan,  Ribbert,  Landau, 
and  Pick  have  advanced  the  theory  that  there  may  be  suppression 
of  the  ectoderm  and  overgrowth  of  the  entoderm  in  atypical  dermoids. 
Some  would  see  pseudomucinous  cystadenoma  as  the  expression  of 
a  one-sided  development  of  the  intestinal  part  of  a  teratoma,  a  theory 
which  has  not  met  the  approval  of  others. 

Multiple  Dermoids. — Multiple  dermoids  are  not  unusual.  Novak, 
in  1909,  was  able  to  collect  but  21  cases  from  the  literature:  7  of  these 
were  bilateral.  He  added  2  cases.  One  case,  a  woman  of  thirty-nine, 
had  ten  dermoids  in  the  right  ovary  and  eleven  in  the  left.  Some 
embryonal  rudiments  had  a  very  complicated  structure.  He  found 
skin,  hair,  sebaceous  and  sweat  glands,  central  nervous  system, 
ganglia,  peripheral  nerves,  meninges  with  chromatophores,  corpora 
amylacea,  buccal  cavity  with  salivary  glands  and  teeth,  pharynx  with 
tonsil,  intestinal  mucosa,  thyroid,  cartilage,  bone  and  smooth  muscle. 
There  was  also  tissue  which  was  either  a  prostate  or  adenomyoma  and, 
what  was  never  before-  described,  a  structure  resembling  a  hyper- 
nephroma.  Other  dermoid  plugs  showed  a  very  simple  structure.  The 
other  case  was  a  seventeen-year-old  girl  containing  six  dermoids  in 
the  right  ovary  and  four  in  the  left,  completely  separated  from  each 
other.  Some  showed  highly  differentiated  structure.  The  largest 
number  of  multiple  dermoids  reported  before  Novak's  case  was  that  of 
Schroeder  in  which  there  were  four  dermoids  in  one  ovary  and  seven 
in  the  other.  Wilms  states  that  there  must  be  a  complete  fetal  rudi- 
ment in  each  anlage  for  true  multiplicity,  since  the  condition  may  be 
simulated  by  transplantation  of  elements,  especially  when  the  dermpid 
constitutes  one  part  of  a  large  cystadenoma.  The  secondary  cysts  in 
these  cases  do  not  show  the  typical  embryonal  rudiment. 

Malignant  Degeneration  of  Dermoids. — The  cystic  teratomata  are, 
in  general,  benign  tumors.  They  grow  slowly,  remain  inclosed  in  a 
definite  capsule,  and  do  not  possess  invasive  properties.  Rupture  of 
the  cyst  and  dissemination  of  its  contents  may  be  followed  by  im- 
plantations upon  the  peritoneum,  although  this  is  not  the  rule.  When 
it  does  occur,  there  result  tiny  cysts  with  typical  dermoid  contents, 
some  with,  and  some  without,  hair.  An  inflammatory  reaction  usually 
incloses  the  escaped  tumor  contents.  An  independent  growth  of  these 
implantations,  such  as  occurs  in  pseudomyxoma  peritonei,  has  not  been 
reported. 

CARCINOMATOUS  CHANGES. — Carcinoma  may  develop  in  an  ovarian 
dermoid  in  three  ways:  (i)  by  direct  extension  from  a  carcinoma  of  an 
adjacent  organ,  or  by  metastases  from  a  more  distant  one;  (2)  by  exten- 
sions from  a  carcinoma  which  has  developed  in  the  ovarian  tissue  not  con- 
cerned with  the  dermoid  growth;  the  carcinoma  of  the  ovary  may  be 


TUMORS    OF    THE    OVARY  363 

primary,  as  in  malignant  degeneration  of  a  preexisting  cystadenoma,  or 
metastatic,  from  primary  cancer  elsewhere;  (3)  by  malignant  degeneration 
of  the  epithelial  structures  of  the  dermoid  itself. 

Carcinoma  arising  in  the  epithelial  structures  of  the  dermoid  itself  is 
considered  a  rather  rare  condition.  Yet  Spalding  believes  that  more  cases 
will  be  found  if  all  dermoids  are  subjected  to  careful,  gross  and  microscopic 
examinations,  since  the  tumor  is  constantly  exposed  to  chronic  irritation 
by  the  hair  and  other  cyst  contents. 

Lippert  estimates  the  frequency  of  carcinoma  arising  within  the  dermoid 
as  3  per  cent.  Yet  Williamson  and  Barris,  in  1911,  could  collect  only  32 
cases  which  had  been  reported  in  the  literature.  Furthermore,  a  critical 
analysis  of  the  reports  convinced  them  that  the  evidence  was  not  sufficient 
in  14  cases  to  warrant  the  diagnosis  that  the  cancer  had  originated  in  the 
dermoid  tissue.  Frankl,  in  1920,  states  that  he  wras  able  to  collect  60 
cases  when  adding  a  case  of  his  own.  Since  then,  cases  have  been  reported 
by  Spalding,  Boettger  and  Eisenstadter.  Practically  all  of  the  cases  are 
squamous  cell  carcinoma.  They  are  usually  of  the  cornifying  type  arising 
from  the  dermoid  skin.  There  are  only  two  cases  reported  of  glandular 
carcinoma.  Friedlander's  case  was  an  adenoma  of  a  sweat  gland.  Yama- 
giwa's  case  was  supposed  to  arise  from  an  anomalous  mammary  gland. 
Although  carefully  described,  there  has  been  objection  to  the  diagnosis. 

Squamous  epithelial  cancers  are  more  common  because  of  the  greater 
activity  of  the  epiblastic  elements  of  the  tumor  (Boettger).  Frankl  sug- 
gests that  the  carcinoma  may  be  of  the  same  age  as  the  dermoid  and  may 
arise  from  the  first  cells,  a  point  which  is  only  theoretical.  The  majority 
feel  that  the  cancer  arises  from  the  cells  of  the  differentiated  tumor,  either 
in  the  dermoid  plug,  or  in  the  wall  of  the  tumor. 

The  results  of  operation  have  been  usually  bad,  since  the  case  is  most 
often  well  developed  when  it  comes  to  operation.  Spalding  calls  attention 
to  the  fact  that  the  prognosis  of  early  cancers  should  be  very  good  because 
of  the  thick,  protecting  capsule  of  the  dermoid.  Yet  there  are  few  cases 
which  have  been  presented  as  convincing  cures.  Williamson  and  Barris' 
case  lived  seven  years  after  her  operation  at  sixty.  Pfannenstiel's  case  re- 
mained well  eight  years  after  operation,  as  did  Boestrom's  for  eleven  and 
a  half  years  after  operation. 

SARCOMATOUS  DEGENERATION. — Sarcomatous  degeneration  of  a  der- 
moid occurs  far  more  rarely,  since  it  is  more  apt  to  be  noted  in  association 
with  a  dermoid,  when  it  arises  from  the  ovarian  tissue  not  included  in  the 
dermoid.  Two  cases  of  melanosarcoma  arising  in  the  dermoid  skin  have 
been  described  by  Amann  and  Lorraine.  The  tumor  pigment  was  identical 
with  the  color  of  the  hair  in  both  cases.  Ludwig  described  two  nonpig- 
mented  sarcoma.  Holtschmidt's  case  occurred  in  a  cyst  whose  buccal 
cavity  contained  teeth.  Schwertassek  described  6  cases  of  round-  or  spindle- 
cell  sarcoma.  Kroemer  found  i  case  which  may  be  of  endothelial  origin. 

COMPLICATIONS   OF    DERMOIDS. — Complications   are    rather   common, 


364 


PELVIC    NEOPLASMS 


especially  torsion  of  the  pedicle.  .Sanger  found  6  cases  of  torsion  in  33 
dermoids.  Storer,  in  248  cysts,  which  had  undergone  tortion  found  43 
dermoids  (17.5  per  cent).  Infection  was  formerly  common  after  tor- 
sion. It  resulted  from  operative  interference,  the  trauma  of  labor,  or  by 
extension  of  infection  from  neighboring  organs.  Even  when  sterile,  the 


FIG.  74. — DERMOID  CYST  OF  OVARY  WHICH  HAD  OFFERED  OBSTRUCTION  TO  LAHOR. 
masses  of  light-colored  hair  are  clearly  shown. 


The 


cyst  contents  are  extremely  irritating  to  the  peritoneum.     Rupture  of  a  cyst 
may  be  followed  by  chemical  peritonitis. 

Dermoids  often  complicate  pregnancy.  They  do  not  appear  to  favor 
sterility,  since  Manton,  in  331  cases,  found  73  single  and  19  double  der- 
moids associated  with  pregnancy.  Ehrenfest  removed  a  dermoid  cyst  of 


TUMORS    OF     THE    OVARY  365 

one  ovary  about  the  fourth  month  of  a  first  pregnancy.  He  left  at  the 
time  a  small  dermoid  on  the  other  ovary.  The  pregnancy  terminated  nor- 
mally and  the  patient  has  since  borne  another  child.  The  dermoid  is  likely 
to  prolapse  in  the  pelvis  and  fall  in  advance  of  the  fetal  head.  We  have 
seen  2  such  cases. 

SYMPTOMS. — There  is  nothing  characteristic  in  the  symptoms.  They 
may  be  slight,  or  absent.  Menstrual  disturbances  are  very  uncommon.  The 
patient  may  complain  of  a  feeling  of  weight  in  the  pelvis  or  a  sense  of 
pressure  on  the  bladder  and  rectum.  The  various  complications  carry  their 
own  symptomatology. 

DIAGNOSIS. — The  position  of  the  tumor  often  gives  a  hint  as  to  the 
diagnosis,  since  the  long  pedicle  permits  the  growth  to  rise  early  in  the 
abdomen.  Large  amounts  of  characteristic  contents,  as  hair,  may  be  recog- 
nized by  the  examining  fingers.  Occasionally,  a  bone  may  be  felt.  The 
X-ray  may  give  valuable  information.  The  diagnosis  may  be  more  difficult 
when  dermoids  are  present  with  other  tumors,  as  fibroids  and  pseudomu- 
cinous  cysts.  The  fact  that  they  occur  frequently  in  infantism  or  genital 
malformations  should  excite  the  suspicion  that  the  tumor  is  a  dermoid. 

TREATMENT. — The  treatment  is  operative  removal,  without  puncture  of 
the  cyst,  after  careful  inspection  of  the  other  ovary.  The  tumor  should  be 
examined  immediately  for  evidence  of  malignant  degeneration. 

PROGNOSIS. — The  tumors  are  benign  and  remain  cured  after  operation, 
unless  there  has  been  malignant  degeneration.  The  prognosis,  therefore, 
is  governed  by  the  presence  or  absence  of  complications. 

Teratoma. — The  solid  teratoma  are  much  more  rare  than  the  cystic 
teratoma  or  dermoids  of  the  ovary.  They  resemble  them  in  that  they 
usually  are  made  up  of  all  three  germinal  layers.  The  tissues,  however, 
are  of  the  early  embryonal  stage,  and  do  not  reproduce  the  highly 
developed  and  differentiated  body  structures  which  may  be  presented 
in  the  dermoid  tumors.  On  the  contrary,  the  cells  usually  occur  in  a 
confused  and  complex  mass  described  by  von  Rindfleisch  as  a  histo- 
logical  potpourri. 

Robert  Frank,  in  1907,  was  able  to  collect  but  52  certain  cases  from 
the  literature.  He  found  4  other  doubtful  ones.  It  is  a  disease  of 
youth  and  middle  age.  Rowland  Harris,  in  1917,  found  21  cases  in 
patients  under  fourteen,  9  of  which  had  been  included  in  Frank's 
statistics.  The  2  youngest  cases  were  three  years,  and  three  years 
and  eight  months  respectively.  The  oldest  of  Eden  and  Lockyer's 
16  cases  was  thirty  years.  Frank  found  4  still  older,  the  oldest  of  which 
was  forty.  No  case  yet  described  was  present  in  a  woman  who  had 
reached  the  menopause.  Twenty-two  of  the  patients  in  Frank's  series 
had  never  borne  children.  Nine  had  been  pregnant.  No  details  are 
given  in  the  remainder  of  the  cases. 

The  teratoma,  almost  without  exception,  are  unilateral,  well-pe- 
dunculated  tumors,  which  rarely  present  adhesions  except  as  a  con- 


3 66  PELVIC   NEOPLASMS 

sequence  of  torsion  of  the  pedicle.  They  form  coarsely  nodular  tumors 
with  rounded  contour.  They  may  preserve  the  form  of  the  ovary. 
The  size  varies.  The  small  tumors  are  found  usually  only  accidentally, 
or  when  there  are  complications  as  torsion  of  the  pedicle.  The  growth 
may  attain  considerable  size.  Falk's  case  weighed  fifty  pounds  at  post 
mortem. 

The  rate  of  growth  is  extremely  rapid  in  cases  which  have  been 
under  observation.  The  tumor  was  known  to  be  present  for  seven 
and  a  half  months  before  operation  in  24  of  Frank's  52  cases. 

On  section,  the  tumors  are  never  entirely  solid,  since  they  contain 
cystic  spaces  of  various  size  lined  by  epithelium.  Some  may  resemble 
solid  carcinoma  from  which  they  may  be  distinguished  only  with  a 
microscope.  Usually,  however,  the  sebaceous  content  of  the  cysts 
and  the  presence  of  hair  indicate  their  nature.  Not  all  cysts  present 
these  structures.  Some  have  a  smooth  mucous  lining,  and  a  clear 
mucous  content.  Inspection  of  the  cut  surface  of  the  tumor  often 
shows  islands  of  bone  and  cartilage,  or  the  rudiments  of  teeth.  The 
section  may  be  mottled  with  punctate  points  of  black  pigment,  or  dis- 
coloration due  to  hemorrhage. 

Microscopic  section  shows  a  coating  of  fibrous  tissue.  In  this  may 
be  ovarian  stroma.  Functionating  tissue  is  more  likely  to  lie  near 
the  pedicle.  The  groundwork  of  the  tumor  is  composed  of  embryonic 
tissue  in  which  is  scattered  the  various  epithelial  structures.  The 
embryonic  connective  tissue  may  appear  as  if  myxomatous  or  sarcoma- 
tous.  The  entire  mass  is  divided  into  lobules  by  thin  connective  tissue 
septa. 

The  ectodermal  structures  are  variously  represented.  Some  tumors 
contain  only  skin-lined  cysts,  without  other  epidermal  structures. 
Others  present  skin  containing  hair,  sebaceous  and  sweat  glands. 
There  may  also  be  rudiments  of  young  teeth.  The  brain  is  repre- 
sented by  islands  of  rudimentary  nerve  tissues.  The  ventricle  is  sug- 
gested by  irregular  tubules  and  may  be  identified  by  the  high  embry- 
onic neuro-epithelium.  A  choroidal  plexus  may  be  very  well  marked. 
There  may  be  primitive  eyes  which  often  contain  pigment  of  the  retina 
or  choroid.  Neuro-epithelioma  and  glioma  have  been  observed  arising 
from  the  brain  structures.  Adenocarcinoma  has  been  described  aris- 
ing from  glandular  tissue. 

The  mesodermic  structures  are  well  represented.  There  may  be 
elastic  or  fibrocartilage,  or  hyaline  cartilage.  The  latter  is  more  com- 
mon and  may  be  surrounded  by  perichondrium.  Bone  may  be  present 
as  partly  calcified  spines  with  well-developed  osteoblastic  areas. 
Smooth  muscle  may  occur  in  large  quantities  and,  contrary  to  the  con- 
dition found  in  dermoids,  the  striated  muscle  may  be  well  developed. 

The  entoderm  is  represented  by  the  high,  columnar  epithelium  of 
the  intestinal  tract.  Occasionally,  it  is  differentiated  into  recognizable 


TUMORS    OF    THE    OVARY  367 

or  intestinal  rudiments.  There  may  be  ciliated  epithelial  canals  of  the 
respiratory  tract,  accompanied  by  mucous  glands,  hyaline  cartilage  and 
smooth  muscle. 

The  tumors  metastasize  usually  by  peritoneal  implantation, 
although  there'  may  be  direct  extensions  to  the  retroperitoneal  lymph 
glands.  A  few  cases  have  shown  visceral  metastases  in  the  liver, 
lungs,  or  brain.  The  metastases  are  usually  of  indifferent  embryonic 
sarcomatous  tissue,  yet  complex  teratomatous  metastases  have  been 
observed  in  the  peritoneum,  in  the  retroperitoneal  glands,  and  in  the 
liver. 

Struma  Ovarii. — This  is  a  tumor  of  the  ovary  which  is  composed 
largely  or  wholly  of  tissues  more  or  less  closely  resembling  normal  thyroid. 
The  structures  contain  iodin.  They  are  usually  malignant,  give  metastases, 
and  produce  ascites.  They  represent  teratoma  in  which  one  germinal 
layer  has  developed  far  in  advance  of  the  others. 

Pick  is  responsible  for  creating  interest  in  this  most  unusual  tumor. 
He  called  attention  to  the  fact  that  the  tumor  described  by  Gottschalk  as 
folliculoma  malignum  strongly  resembled  adenoma  of  the  thyroid.  Since 
he  found  thyroid  tissue  in  six  of  twenty-one  teratoma,  he  argued  that 
thyroid  tissue  might  so  overgrow  the  remaining  structures  of  a  teratoma 
that  it  would  remain  as  the  only  recognizable  element.  Saxen's  case  of  a 
single  tooth  in  an  otherwise  normal  ovary  appeared  to  substantiate  this 
view.  Others,  as  Kretschman,  believed  that  they  were  metastases  from 
primary  thyroid  tumors.  Walthard's  work  confirmed  Pick's  view.  He 
proved  the  teratomatous  elements  in  three  so-called  thyroid  tumors  by 
serial  sections.  Such  work  was  necessary,  since  stratified  squamous  epithe- 
lium, sebaceous  and  sweat  glands  were  found  only  in  nine  successive  sec- 
tions of  an  ovarian  tumor  which  appeared  to  be  constituted  entirely  of 
thyroid  tissue.  The  presence  of  iodin  in  the  alveoli  was  demonstrated  by 
Robert  Meyer,  thus  disproving  the  view  of  those  who  regarded  the  growth 
as  degenerations  of  ordinary  cystadenoma. 

Trapl  made  the  interesting  observation  that,  after  removing  the  ovarian 
thyroid,  there  was  compensatory  nypertrophy  of  the  normal  thyroid,  sug- 
gesting that  the  tumor  gave  off  an  internal  secretion.  Trapl  studied  the 
frequency  of  other  teratomatous  tissues  in  the  so-called  thyroid  tumors. 
The  thyroid  structure  was  present  alone  in  5  cases.  There  were  bone  and 
cartilage  also  in  one,  bone  and  muscle  in  one,  cartilage  and  sweat  glands  in 
one,  a  ductus  thyrioglossus  in  one,  structureless  connective  tissue  in  one, 
cartilage  and  squamous  epithelium  in  one,  squamous  epithelium  and  sweat 
glands  in  one,  hair,  skin  and  intestinal  rudiments  in  one,  bones  and  two 
teeth  in  one,  and  epidermis  and  hair  in  one  other.  These  observations  were 
necessary  to  place  the  teratomatous  structure  of  the  tumor  on  a  firm  basis, 
since  Bauer  has  recently  described  a  similar  tumor  which  seemed  to  arise 
by  down-growth  from  the  superficial  ovarian  epithelium. 

It  appears  as  if  struma  ovarii  may  occur  in  two  forms  and  be  either 


3 68  PELVIC   NEOPLASMS 

benign  or  malignant.  Errors  may  readily  arise  from  difficulty  in  inter- 
preting the  histologic  picture  of  the  tumor.  Thus,  the  normal  fetal  thyroid 
before  the  appearance  of  the  alveoli  is  composed  of  compact  cell  masses 
which  may  erroneously  suggest  carcinoma.  Malignancy  is  the  rule,  however, 
in  the  thyroid  ovarian  tumors.  Kretschman's  case  died  from  recurrence 
two  and  three-fourth  years  after  operation.  Tin  cases  of  Polano,  Katsu- 
rada,  Glockner,  Gottschalk,  and  Ealthard  were  considered  malignant,  and 
reported  as  clinically  cured.  The  case  of  Vagedes  has  borne  a  child  since 
her  operation. 

MESODERMAL  DEVELOPMENT  OF  A  TERATOMA.  —  The  question  of 
whether  there  may  be  one-sided  mesodermal  development  of  the  teratoma 
has  not  yet  been  definitely  settled.  The  cases  of  Reiss  and  Jung  of  ovarian 
enchondromata  have  been  so  considered  by  a  number  of  authors.  The  fact 
that  Reiss'  enchondromata  recurred  as  a  carcinoma  caused  Pfannenstiel  to 
believe  that  it  should  be  classified  as  true  teratoma. 

SYMPTOMS  OF  TERATOMA. — Pain  is  usually  an  early  symptom.  Intes- 
tinal disturbances  are  generally  noted.  There  may  be  diarrhea,  or  consti- 
pation, often  due  to  pressure  or  a  reflex  phenomenon  following  torsion. 
Vomiting,  nausea  and  anorexia  accompany  torsion  of  the  pedicle.  The 
abdomen  may  rapidly  enlarge  from  growth  of  the  tumor  mass  or  the 
development  of  ascites.  The  latter  is  present  in  more  than  half  the  cases. 
An  unusual  feature  in  Harris's  case  was  precocious  sexual  development, 
since  menstruation  took  place  in  a  child  of  five,  seven  months  before 
removal  of  the  tumor.  The  phenomenon  disappeared  after  operation. 
This  symptom  has  not  occurred  in  other  cases  in  which  the  tumor  appeared 
before  puberty. 

DIAGNOSIS. — The  diagnosis,  in  view  of  the  very  great  rarity  of  the 
tumor,  can  seldom  be  made  before  operation.  The  diagnosis  of  malig- 
nancy can  ordinarily  be  made  at  operation.  The  exact  nature  of  the  growth 
is  usually  determined  when  the  tumor  is  sectioned  after  removal. 

TREATMENT. — The  treatment  is  operative  removal.  Because  the 
tumors  are  ordinarily  malignant,  the  operation  should  consist  in  removal 
of  the  adnexa  of  the  affected  side  as  widely  as  possible,  and  supravaginal 
hysterectomy  together  with  the  adnexa  of  the  opposite  side. 

PROGNOSIS. — The  prognosis  is  not  good.  The  outcome  was  not  known 
in  10  of  the  37  cases  collected  by  Frank.  Two  cases  were  alive  and  well  for 
short  intervals,  namely,  one  and  six  months  after  operation.  There  were 
only  3  other  cases  living,  2  presenting  recurrences.  One  was  well  after 
eight  and  a  half  years. 

Pfannenstiel's  series  is  a  little  more  encouraging,  yet  since  it  was  col- 
lected about  the  same  time  as  Frank's,  it  is  not  possible  to  say  how  far  the 
series  overlapped.  Of  42  cases,  the  outcome  was  not  known  in  6;  4  un- 
operated  cases  died.  There  were  5  deaths,  or  16  per  cent,  in  32  operations. 
Of  the  27  survivors,  16  died  from  recurrence  within  one  and  a  half  years 
(59  per  cent).  Four  were  lost  after  a  short  period  of  observation.  Of  the 


TUMORS    OF    THE    OVARY  369 

remaining  7,  I  was  well  one  and  a  half  years,  I  at  four  years,  I  at  five 
years,  I  died  at  six  years  from  tuberculosis  without  evidence  of  recurrence, 
i  was  well  at  eight  years,  i  at  eight  and  a  half  years,  and  i  at  ten  years. 
Thus  there  were  4  cases  of  the  32  which  remained  cured  for  five  years. 

STROMATOGENOUS  TUMORS 

The  stromatogenous  ovarian  tumors  are  of  the  connective  tissue 
type  and  develop  from  the  ovarian  stroma.  They  are  neither  as  com- 
mon, nor  of  as  great  clinical  importance,  as  the  epithelial  neoplasms. 
They  are  divided  into  three  general  groups:  (i)  benign  tumors  of  the 
connective  tissue  type;  (2)  sarcoma;  and  (3)  periendothelioma  and 
endothelioma. 

Under  the  benign  stromatogenous  ovarian  tumors  are  grouped 
fibroma,  myoma,  osteoma,  chondroma,  hemangioma,  and  lymphan- 
gioma. 

Fibroma  and  Myoma. — Ovarian  fibromyoma  and  myoma  are  rare 
tumors.  Together  they  constitute  about  2.5  per  cent  of  all  ovarian 
tumors.  There  are  comparatively  few  series  of  size.  Basso  has  re- 
ported 4  cases  and  has  collected  45  others  from  the  literature.  Kroemer 
found  only  5  in  280  ovarian  tumors.  Lohlein  found  7  in  172  ovarian 
neoplasms,  of  which  2  were  bilateral.  Kroemer  studied  19  cases  of 
which  17  were  fibromyomata  and  2  pure  myomata.  Peterson  has 
collected  84  cases  of  fibromyomata. 

Little  is  known  concerning  the  etiology.  It  is  rather  remarkable 
that  these  tumors  occur  so  rarely,  since  scar  tissue  theoretically  results 
in  the  ovary  as  a  monthly  phenomenon  during  menstrual  life.  It  is 
prevented  from  developing  by  the  unique  method  by  which  the  corpus 
luteum  is  absorbed. 

The  age  at  which  fibroids  have  been  found  ranges  from  eight  to 
eighty-three  years.  They  are  rarely  observed  before  the  age  of 
twenty-five  and  are  found  most  frequently  in  the  fourth  and  fifth 
decades. 

These  tumors  are  probably  most  frequently  derived  from  the  tis- 
sues of  the  ligamentous  supports  of  the  ovary  rather  than  from  the 
ovarian  stroma.  They  are  usually  unilateral  and  are  bilateral  only 
in  about  one-fifth  of  the  cases.  The  bilateral  cases  are  often  associated 
with  uterine  fibroids  which  they  resemble  in  nearly  every  way.  They 
grow  slowly  but  may  attain  considerable  size.  Whitridge  Williams' 
patient  carried  her  tumor  for  thirty-seven  years;  it  weighed  twenty- 
two  pounds.  The  largest  tumor  of  which  we  find  record  is  Clemens, 
which  weighed  forty  kilograms,  and  whose  presence  was  known  for 
ten  years.  Spiegelberg  and  Jacoby  both  described  tumors  weighing 
thirty  kilograms.  Sturmer  reported  a  tumor  that  weighed  seventeen 
and  a  half  kilograms  in  a  Hindu  woman. 


370  PELVIC  NEOPLASMS 

The  ovarian  fibromata  may  present  as  diffuse,  or  circumscribed, 
growths.  In  the  former,  the  whole  ovary  is  replaced  by  the  new 
growth,  while  the  latter  is  localized  to  one  part  of  the  ovary  or  arises 
from  that  organ  by  a  definite  pedicle. 

The  diffuse  fibroma  usually  retains  the  normal  contour  of  the  ovary 
until  it  has  attained  considerable  size  when  it  presents  a  spherical  or 
ovoid  contour.  Infrequently,  it  is  of  kidney  shape,  with  a  marked 
indentation  at  the  hilus.  The  circumscribed  forms  are  often  found  in 
a  lateral  pole  of  the  ovary.  They  are  not  encapsulated  and  there  may 
be  no  sharp  line  of  demarcation  between  the  normal  tissue  and  the 
neoplasm.  Normal  stroma  may  always  be  found  on  their  outer  sur- 
faces. These  tumors  are  well-pedunculated,  firm,  hard  growths.  On 
gross  section,  they  appear  of  white  or  grayish  white  color.  The  cut 
surfaces  are  sometimes  mottled  by  hemorrhage.  The  characteristic 
whorl-like  arrangement  of  fibrous  tissue  is  invariably  present.  Under 
the  microscope  the  tumors  present  the  characteristic  appearance  of 
fibroids  in  general.  There  are  varying  proportions  of  connective  tissue 
cells  and  fibers  and  blood  vessels.  The  younger  and  smaller  tumors 
are  the  more  cellular.  The  tumor  fibers  are  often  arranged  concen- 
trically about  the  blood  vessels  which  are  usually  merely  capillary 
spaces  lined  by  epithelium.  The  tumor  may  contain  soft  areas  because 
of  edema  or  myxomatous  degeneration.  Cystic  spaces  may  result 
from  degeneration  or  from  lymphangiectasis.  Calcareous  degeneration 
is  not  often  found.  Rarely,  necrotic  areas  may  be  more  or  less  encap- 
sulated within  a  calcified  shell.  Occasionally,  a  corpus  fibrosum  or 
corpus  luteum  is  filled  with  calcareous  deposits  when  it  becomes  a 
so-called  "ovarian  stone." 

Rokitansky  called  attention  to  a  fibroma  which  arose  from  a  path- 
ological increase  in  the  connective  tissue  of  a  corpus  fibrosum.  The 
"ovarium  gyratum"  of  Adler  is  due  to  a  superficial  fibrosis  in  the  cortex 
of  both  ovaries  which  replaces  that  layer  and  causes  an  enlargement 
of  the  ovary.  This  hypertrophy  is  subsequently  followed  by  atrophy 
and  the  ovary  presently  becomes  extremely  firm,  with  a  markedly 
corrugated  cortex.  Very  often,  one  finds  small,  superficial,  papillary 
fibromata  appearing  on  the  side  of  the  ovary  rather  near  the  hilum. 
They  are  wartylike  structures  which  are  of  no  clinical  or  pathological 
significance,  except  for  the  fact  that  tumors  of  more  serious  import 
are  sometimes  mistaken  for  them.  Early  superficial  papillae  of  solid 
cystadenomata  and  some  of  the  implantation  metastases  from  malig- 
nant tumors  may  resemble  them  in  a  rather  general  manner.  They 
are  usually  more  crenated,  however. 

Symptoms. — The  clinical  symptoms  vary  and  are  usually  slight 
until  the  tumor  attains  considerable  size.  There  is  no  definite  rela- 
tionship between  the  tumor  and  menstrual  disturbances  unless  the 
growth  is  bilateral,  when  it  may  be  accompanied  by  amenorrhea  and 


TUMORS    OF    THE    OVARY  371 

sterility.  Peterson  believes  that  the  menopause  is  usually  retarded 
in  single  tumors.  Dysuria  is  a  rather  common  complaint.  The  ma- 
jority of  the  symptoms  are  caused  by  the  size  of  the  tumor  or  by  com- 
plications. They  are  very  likely  to  follow  adhesions  which  were  noted 
by  Peterson  in  36  per  cent  of  84  collected  cases.  Ascites  is  common, 
especially  in  tumors  of  appreciable  size.  It  occurred  in  40  per  cent 
of  Peterson's  series.  Some  claim  that  it  regularly  accompanies  the 
diffuse  fibroids  but  is  uncommon  with  the  circumscribed  forms.  There 
may  be  large  amounts  of  the  ascitic  fluid.  Olshausen  found  twenty-two 
and  a  half  liters  in  one  of  his  cases.  Ovarian  fibroids  are  rather  fre- 
quently associated  with  other  genital  malformations.  The  bilateral 
tumors  often  coexist  with  uterine  fibroids.  The  tumors  may  block 
labor  when  they  have  prolapsed  during  pregnancy  into  the  pelvis  and 
are  in  advance  of  the  fetal  head.  Cachexia  is  common  with  the  large 
tumors. 

Diagnosis. — They  cannot  always  be  differentiated  from  other  solid 
tumors  of  the  ovary,  especially  since  they  often  present  certain  features 
usually  associated  with  malignancy,  namely,  ascites  and  cachexia.  The 
history  of  slow  growth  is  of  value  when  it  is  possible  to  obtain  it.  The 
tumors  are  often  mistaken  for  a  malignant  condition  in  the  liver  asso- 
ciated with  ascites.  One  of  us  has  seen  2  cases  which  were  considered 
inoperable  cancer  and  had  been  treated  only  by  tapping.  Both  recov- 
ered after  operation. 

Prognosis. — The  prognosis  is  good,  since  the  tumors  are  benign. 

Treatment. — The  treatment  is  operative  removal.  This  usually 
may  be  done  without  difficulty,  since  the  tumors  are  usually  well 
pedunculated  and  the  adhesions  are  not  extremely  dense. 

Osteoma  and  Chondroma. — The  majority  of  the  tumors  described 
as  osteoma  are  really  fibroids  which  have  undergone  calcification,  the 
deposit  consisting  of  a  structureless  mass  of  lime  salts.  True  bone 
formation  with  periosteum  and  marrow  has  been  described  only  in 
connection  with  the  dermoids  and  teratoma. 

There  is  considerable  discussion  as  to  whether  there  may  be  a  true 
chondroma  of  the  ovary.  Most  of  the  tumors  described  as  such  are 
now  considered  atypical  teratoma.  Jung  reported  a  case  which  he 
believed  was  due  to  a  metaplasia  of  the  ovarian  stroma.  Kroemer,  and 
some  others,  agreed  with  the  diagnosis,  yet  Robert  Meyer  regarded 
it  as  a  mesodermal  teratoma  and  Kehrer  thought  it  was  a  mixed  tumor 
from  mesodermal  rests  of  the  mullerian  duct. 

Myxorna. — True  myxoma  of  the  ovary  has  not  yet  been  described, 
although  myxomatous  degeneration  is  often  seen  in  fibroid  tumors. 
Myxosarcoma  will  be  considered  with  the  sarcoma  (page  373). 

Angioma. — True  hemangioma  of  the  ovary  is  exceedingly  rare. 
It  is  often  confused  with  tumors  presenting  a  marked  dilatation  of 
the  venous  svstem,  a  condition  which  mav  occur  in  ovarian  tumors  with 


372 


PELVIC  NEOPLASMS 


extreme  and  longstanding  passive  congestion.  Marckwald  reported  a 
hemangioma  the  size  of  a  hazlenut  in  the  median  pole  of  an  ovary  in 
which  was  beginning  a  papillary  cyst.  Kroemer  reported  a  small  one 
found  in  a  serous  cystadenoma.  Bilateral  ovarian  hemangiomata  have 
been  described  by  Orth,  and  Payne.  Orth's  case  was  a  child  who  also 
presented  similar  tumors  in  the  skin  and  in  several  of  the  inner  organs. 

Lymphangiomata  may  present  as  tumors  distinguishable  from 
lymphangiectases  which  are  often  seen  in  ovarian  fibroids.  They 
are  grayish  white  tumors  which  bear  some  resemblance  to  fibromata, 
although  they  are  not  so  firm.  On  section,  they  present  a  meshwork 
of  cystic  cavities,  varying  in  size  from  a  pinhead  to  seven  or  eight 
centimeters  in  diameter.  The  cysts  are  lined  by  a  delicate  endothelium, 
and  contain  a  slightly  turbid  light-colored  fluid.  There  is  no  epithelial 
debris.  There  are  few  blood  vessels  in  the  tumor.  Kroemer  has  re- 
ported 2  cases,  one  of  which  showed  considerable  proliferation  of  both 
the  endothelium  and  the  stroma. 

Sarcoma  of  the  Ovary. — Sarcoma  of  the  ovary  is  a  rare  tumor.  It 
may  be  a  primary  growth,  may  represent  a  malignant  degeneration  of 
an  ovarian  fibroid,  or  may  occur  as  metastases  from  tumors  primary 
elsewhere  in  the  body. 

Little  is  known  concerning  the  etiology.  They  have  been  observed 
at  all  ages  from  fetal  life  to  women  of  the  sixty-sixth  year.  Forty 
per  cent  of  reported  cases  have  been  observed  in  women  less  than 
twenty-five  years  of  age.  The  average  age  of  incidence  is  thirty-two 
years.  Hubert  collected  200  ovarian  sarcomata  in  children,  6  of  which 
occurred  in  the  fetus. 

PRIMARY  OVARIAN  SARCOMA. — Primary  ovarian  sarcoma  is  a  malig- 
nant neoplasm  of  mesodermic  origin.  There  are  several  hystologic  types 
which  may  present  singly  or  in  combination.  Thus,  there  are  spindle-cell, 
round-cell  or  mixed-cell  sarcoma.  Myosarcoma,  chondrosarcoma,  and 
melanosarcoma  have  also  been  described,  yet  there  is  much  doubt  as  to 
whether  these  are  other  than  sarcomatous  changes  in  dermoids.  Myxo- 
sarcoma  is  rather  common. 

In  their  gross  characteristics,  they  rather  resemble  ovarian  fibroids. 
They  are  solid  tumors  with  a  smooth  or  slightly  nodular  surface,  which 
tend  to  preserve  the  general  shape  of  the  ovary,  although  they  may  be 
rounded  or  oval  in  form.  They  are  nearly  always  pedunculated  and 
are  not  nearly  as  likely  to  be  bilateral  as  are  the  ovarian  carcinoma. 
Bilateral  growths  occur  in  rather  less  than  one-third  of  the  cases. 
The  round-cell  type  are  more  frequently  bilateral  than  the  other 
ovarian  sarcoma. 

The  sarcoma  grows  rapidly.  The  cellular  types  show  the  most 
rapid  development.  Tumors  occurring  in  young  patients,  and  especially 
those  which  develop  during  pregnancy,  may  attain  very  large  size 
within  a  comparatively  short  time.  Chrobak  reported  a  round-cell 


TUMORS    OF    THE    OVARY  373 

sarcoma  which,  in  twenty-three  days,  increased  from  the  level  of  the 
umbilicus  to  the  margin  of  the  ribs. 

On  section,  they  are  firm  and  resemble  the  fibroids,  especially  the 
fibrosarcomata.  The  round-cell  types  exhibit  a  softer  and  more  friable 
surface.  They  are  white  or  pinkish  in  color.  Older  tumors  may  pre- 
sent a  yellowish  tinge.  Degenerative  changes  are  common  and  include 
fatty  degeneration,  necrosis,  hemorrhage  into  the  tumor  substance,  and 
thrombosis.  Cysts  may  result  from  softening  or  from  lymphangiec- 
tasis. 

Under  the  microscope,  the  fibrosarcomata  appear  very  cellular. 
The  spindle  cells  are  closely  packed  but  irregularly  distributed.  They 
may  appear  to  form  the  walls  of  new  blood  vessels  which  are  present  in 
great  abundance.  The  cells  vary  greatly  in  size  and  shape  and  in  the 
chromatin  content  of  their  nuclei.  Mitotic  figures  are  common.  Myx- 
omatous  degeneration  frequently  occurs  in  older  tumors.  Some  of  the 
sarcoma  contain  many  large  irregular  cystic  spaces  lined  by  a  ragged 
layer  of  sarcomatous  tissue  and  containing  serous  or  bloodstained 
fluid.  They  may  result  from  dilatation  of  the  lymph  vessels  or  from 
liquefaction  necrosis. 

The  cells  of  the  round-celled  sarcoma  are  somewhat  more  uniform 
in  size.  They  are  small  and  round,  with  relatively  large,  deep  staining 
nuclei,  surrounded  by  clear  protoplasm.  They  also  may  be  arranged 
diffusely  and  tend  to  be  grouped  about  newly  formed  blood  vessels. 
Sometimes  they  show  an  alveolar  arrangement  when  the  individual 
cells  are  separated  by  a  delicate  connective  tissue  stroma.  Tumors  of 
this  group  also  have  a  strong  tendency  to  necrosis,  softening,  and 
hemorrhagic  infarction. 

Tumors  of  the  mixed-cell  type  are  also  found  containing  not  only 
round  and  spindle  cells  but  multinucleated  giant  cells  as  well. 

Myosarcoma. — Myosarcoma  has  been  described  by  Kroemer.  It 
consists  of  round  and  spindle  cells,  together  with  a  considerable  pro- 
portion of  smooth  muscle  fibers,  some  of  which  showed  a  marked 
hypertrophy. 

True  chondro-osteosarcoma  have  not  been  described.  A  number 
of  cases  regarded  as  such  are  now  placed  in  the  teratomatous  or  mixed 
tumor  grouping. 

Myxosarcoma. — Tumors  consisting  entirely  of  myxosarcomatous 
tissue  have  never  been  described.  However,  myxomatous  areas  are 
frequently  seen  in  all  types  of  sarcoma  of  the  ovary. 

Melanosarcoma. — Melanosarcomata  are  occasionally  found.  In  the 
majority  of  cases,  they  probably  represent  metastases.  They  are  found 
most  often  when  there  is  a  general  melanosarcomatosis,  the  primary 
tumor  usually  being  in  a  cutaneous  nevus.  Frankl  has  collected  40 
such  cases.  Very  rarely  these  tumors  appear  to  be  primary  in  the 
ovary.  Loubergran  and  Rives  collected  7  such  cases.  Herzog  reported 


374 


PELVIC   NEOPLASMS 


another  and  added  2  more  to  the  list,  those  of  Cotton  and  Markus. 
Herzog,  however,  calls  attention  to  the  fact  that  the  larger  proportion 
of  cases  reported  as  primary  are  really  not  such  but  are  rather  second- 
ary, to  some  small  skin  nevus,  which  was  overlooked.  The  only  2 
cases  which  he  believes  are  undoubtedly  primary  are  those  of  Amann 
and  Lorraine.  These  did  not  arise  directly  from  ovarian  stroma  but 
sprang  from  pigment  cells  in  an  ovarian  dermoid.  He  calls  attention  to 
the  fact  that  secondary  melanosarcoma  of  the  ovary  may  occur  in  two 
forms,  a  large  homogeneous  tumor  which  completely  replaces  the  nor- 
mal ovary,  or  as  small  disseminated  nodules  which  are  scattered 
through  the  stroma.  Pregnancy  appears  to  have  been  an  important 
factor  in  causing  dissemination  of  the  growth  in  several  cases. 

Perithelioma,  Angiosarcoma. — Although  all  sarcomata  show  a 
tendency  to  develop  about  blood  vessels,  there  is  a  certain  group  in 
which  the  unit  of  growth  appears  to  be  the  small  blood  vessels  and  the 
tumor  seems  to  arise  from  the  vessel  wall.  In  this  group  from  the  very 
beginning,  there  is  a  new  formation  of  small  blood  vessels,  often  of 
remarkably  even  size.  The  cell  proliferation  holds  pace  with  the  new 
formation  of  blood  vessels.  The  sarcoma  cells  fully  replace  the  vessel 
walls  down  to  an  extremely  fine  intima  and  endothelial  membrane. 
This  type  of  sarcoma  is  usually  described  as  perithelioma.  Kroemer 
calls  attention  to  the  fact  that  there  is  no  definite  perivascular  lym- 
phatic sheath  or  definite  perithelium  and  feels  that  the  term  "hemangio- 
sarcoma"  better  describes  the  condition.  Lymphangiosarcoma  may 
develop  from  such  perivascular  cells  as  lie  about  lymph  vessels.  The 
sarcoma  cells  form  fine,  netlike  strands  about  the  lymph  spaces.  The 
tumor  may  contain  large  giant  cells.  These  tumors  are  frequently  con- 
fused with  the  so-called  endothelioma. 

Metastatic  Ovarian  Sarcoma. — Secondary  ovarian  sarcoma  is  even 
more  rare  than  the  primary  growths.  They  are  very  likely  to  occur  in 
general  melanosarcomatosis.  The  ovaries  become  involved  by  exten- 
sions through  the  lymphatics.  The  ovary  may  also  become  involved  by 
implantation  metastases  through  the  peritoneal  cavity  when  a  uterine 
sarcoma  has  broken  through  the  serosa,  a  rather  rare  condition.  Cir- 
cumscribed sarcoma  nodules  in  an  ovary  which  otherwise  present  as 
normal,  suggest  metastatic  growths. 

METASTASES  FROM  OVARIAN  SARCOMA. — Sarcomata  of  the  ovary  spread 
by  direct  extension  to  the  bowel,  broad  ligament,  and  the  pouch  of 
Douglas.  The  growth  is  soon  disseminated  by  metastases  in  the  order 
of  frequency  to  the  uterus,  tubes,  stomach,  liver,  intestines,  lungs, 
diaphragm,  kidneys,  navel,  vertebra  and  subcutaneous  tissue. 

The  malignancy  varies  greatly  in  the  different  types  of  growths. 
The  more  cellular  structures  exhibit  more  striking  features  of  malig- 
nancy and  are  more  likely  to  involve  both  ovaries. 

SYMPTOMS  OF  OVARIAN  SARCOMA. — The  symptoms  vary  considerably. 


TUMORS    OF    THE    OVARY  375 

They  may  be  lacking  until  the  growth  has  attained  much  size.  Occa- 
sionally, the  presence  of  a  tumor  constitutes  the  only  symptom.  More 
often,  there  is  enlargement  of  the  abdomen  due  to  ascites,  a  condition 
which  is  noted  in  about  70  per  cent  of  cases.  Later,  there  is  pain,  loss 
of  weight,  disturbances  of  digestion,  cachexia,  and  other  features  of 
the  late  stages  of  malignant  disease.  Menstrual  disturbances  are  com- 
mon and  may  occur  when  the  tumor  is  not  large.  There  may  be  menor- 
rhagia  or  amenorrhea,  rarely  metrorrhagia.  When  the  tumor  develops 
in  early  youth,  there  may  be  precocious  puberty.  Reappearance  of 
the  menses  after  the  climacteric  is  not  unusual. 

TREATMENT. — The  treatment  is  removal  of  the  tumor,  together  with 
the  adnexa  of  both  sides  and  the  uterus  by  as  wide  a  dissection  as 
appears  feasible  for  the  individual  case. 

PROGNOSIS. — The  prognosis  for  sarcoma  is  not  good.  Cures  may 
be  obtained  more  commonly  in  the  fibrosarcoma  than  in  the  other 
types,  yet  nothing  but  palliative  relief  will  follow  the  removal  of  a 
tumor  which  has  evidenced  glandular  involvement.  The  round-cell 
sarcomata  are  very  malignant  and  cures  average  only  30  per  cent  in 
the  majority  of  cases  that  have  been  observed  as  short  a  time  as  two 
years.  There  are  no  series  of  size  which  have  been  followed  for  five 
years.  The  literature  abounds  with  cases  in  which  recurrence  has 
occurred  in  a  few  months  after  operation. 

Endothelioma  Ovarii. — There  is  much  dispute  concerning  this  group 
of  tumors.  The  endothelial  cell  occupies  a  more  or  less  intermediate 
position  between  the  connective  tissue  and  the  epithelial  cells.  It  is  a 
modified  mesenchymal  cell,  retaining  its  ability  to  behave  like  a  con- 
nective tissue  cell  while,  morphologically,  it  appears  as  an  epithelial 
cell  and  acquires  some  of  its  functions.  Tumors  derived  from  it 
naturally  show  mixed  characteristics.  Thus  some  of  the  tumors 
resemble  sarcoma  while  others  approach  the  type  of  carcinoma.  This 
has  led  certain  authors,  as  Barrett  and  others,  to  believe  that  many  of 
the  tumors  described  as  atypical  carcinoma  and  sarcoma  are  really  of 
endothelial  origin.  Others  hold  that  there  is  not  yet  proof  that  any 
ovarian  neoplasm  has  developed  from  the  endothelium.  This  school  is 
represented  by  Meyer  and  Ribbert.  Certain  it  is  that  the  majority  of 
the  tumors  reported  as  endothelioma  soon  after  the  type  was  defined 
are  now  believed  to  have  some  other  origin.  Thus  Schlagenhaufer 
and  Polano  showed  that  many  of  them  were  metastatic  carcinoma, 
while  others  were  struma  ovarii. 

Leopold,  in  1874,  reported  the  first  example  of  endothelioma,  call- 
ing it  lymphangioma  cystomatosum.  In  1879,  Marchand  described  two 
ovarian  tumors  which  he  felt  were  derived  from  the  endothelium  of  the 
lymph  or  blood  vessels.  They  bore  certain  resemblances  to  sarcomata. 
Isolated  cases  were  reported  during  the  next  decade  and  until  Pick,  in 
1894,  made  the  first  detailed  study.  He  divided  them  into  three 


376  PELVIC  NEOPLASMS 

morphologic  types:  (i)  those  having  an  alveolar  arrangement;  and 
(2)  those  having  a  columnar  arrangement;  (3)  those  having  a  tubular 
or  glandular  arrangement.  Later  study  has  shown  that  all  these  types 
may  be  and  frequently  are  present  in  one  tumor. 

Barrett,  in  1907,  reported  85  cases  which  he  regarded  as  authentic 
and  added  a  case  of  his  own.  In  addition  to  these,  he  cites  a  consider- 
able number  of  cases  which  he  has  been  unable  to  verify.  He  drew  up 
the  following  clinical  picture  from  a  study  of  the  cases.  The  age 
incidence  was  from  seven  to  sixty-four  years.  The  greatest  number 
occurred  in  the  fifth  decade.  Heredity  did  not  appear  to  have  much 
bearing  upon  etiology.  The  symptoms  developed  suddenly.  Many 
cases  were  operated  after  the  tumor  or  its  symptoms  had  been  observed 
for  only  a  few  weeks.  Pain  in  the  pelvis  was  a  frequent  complaint. 
There  was  seldom  menstrual  disturbances.  Marasmus  and  cachexia 
were  occasionally  seen.  The  presence  of  the  tumor  formed  the  only 
complaint  in  a  few  cases. 

The  tumors  varied  in  size  from  a  walnut  to  a  mass  weighing  ninety- 
three  pounds.  The  majority  were  of  the  size  of  a  child's  or  an  adult's 
head.  Single  tumors  occurred  in  59  cases;  bilateral  in  21 ;  not  stated  in 
9.  The  remaining  ovary  was  found  to  have  become  involved  later  in  a 
number  of  cases.  The  tumors  varied  in  consistency.  Some  were  soft, 
appearing  as  soft  as  brain  tissue,  while  others  were  fairly  hard.  Many 
were  cystic.  The  rapidity  of  growth  varied  greatly.  Ascites  was 
usually  present  and  sometimes  was  as  much  as  eight  or  ten  liters.  The 
fluid  was  most  often  light,  clear-colored,  but  occasionally  contained 
sanguinopurulent  material. 

Metastases  were  common.  They  were  found  on  the  uterus,  opposite 
ovary,  peritoneum,  omentum,  liver,  lungs,  cord,  and  vagina.  The  mor- 
tality was  very  high.  Thirty-one  cases  died  a  short  time  after  opera- 
tion. The  majority  of  the  34  cases  reported  as  recovered  were  followed 
only  a  few  weeks  after  operation.  Most  of  the  cases  were  operated 
late. 

Adenomyoma  of  the  Ovary. — Not  more  than  8  cases  of  adeno- 
myoma  of  the  ovary  have  yet  been  described,  although  Norris,  in 
reporting  his  case,  called  attention  to  the  fact  that  the  endometrial 
tissue  was  discovered  only  by  microscopic  examination  and,  therefore, 
might  be  overlooked  in  many  cases.  Microscopically,  the  appearance 
is  identical  with  that  of  adenomyoma  elsewhere.  The  older  cases  were 
thought  to  have  developed  from  the  mesonephros,  but  in  the  light  of 
Webster's  observations  on  ovarian  pregnancy  and  Russell's  and 
Norris's  study  of  adenomyoma  of  the  ovary,  it  seems  more  reasonable 
to  believe  that  they  have  developed  from  mullerian  inclusions  in 
ovarian  tissue.  The  possibility  of  origin  from  germinal  epithelium  has 
not  been  definitely  excluded. 


TUMORS    OF    THE    OVARY  377 

Mesonephric  Tumors  of  the  Ovary. — Small  cysts  of  the  hilum  have 
occasionally  been  reported  as  having  origin  from  remnants  of  the 
wolffian  duct.  Since  Goodall  has  demonstrated  that  all  the  epithelial 
structures  of  the  ovary  are  derived  from  germinal  epithelium,  it  seems 
more  reasonable  to  believe  that  these  small  tumors  which  present  little 
of  clinical  interest  are  derived  from  germinal  epithelium. 

Malignant  Tumors  of  the  Corpus  Luteum. — Malignant  tumors  com- 
posed of  tissues  resembling  growths  which  have  been  derived  from 
lutein  cells  have  been  occasionally  reported  in  the  literature.  Some  of 
these  are  thought  to  have  developed  from  lutein  cells.  The  earliest 
case  was  described  by  Rokitansky  in  1859  an<^  Williamson  and  Barris 
collected  9  cases. 

There  is,  however,  a  group  of  tumors  which  have  been  thought  to 
develop  from  aberrant  adrenal  tissue  in  the  ovary.  They  are  seldom 
found  in  the  ovary  proper  but  are  situated  in  the  mesovarium.  They 
are  small  tumors  of  reddish  yellow  color  composed  of  cells  which 
resemble  the  structure  of  the  cortical  zone  of  the  adrenal  gland.  Ala- 
martine  and  Maurizot,  in  1912,  collected  10  cases.  Considerable  doubt 
has  been  cast  upon  the  possibility  of  an  origin  from  adrenal  rests  by 
Glynn,  who  has  recently  reviewed  all  the  available  material.  Although 
Aschoff  and  Meyer  found  misplaced  adrenal  cells  in  the  broad  ligament 
of  12  per  cent  of  women  studied  by  them,  Glynn  states  that  there  is  no 
proved  case  of  their  presence  in  the  ovary.  He  states  that  the  histo- 
logic  picture  of  the  ovarian  growths  which  have  been  described  as 
hypernephroma  is  quite  unlike  that  of  the  large  primary  and  usually 
malignant  growths  of  the  adrenal,  but  that  it  bore  a  much  closer  resem- 
blance to  the  tumors  usually  regarded  as  of  lutein  origin.  He  states, 
moreover,  that  the  secondary  sex  characteristics,  precocious  puberty, 
and  other  examples  of  suprarenal  virulism  are  absent  in  these  cases, 
although  they  occur  extremely  often  in  the  tumors  which  are  derived 
from  the  suprarenal  cortex.  On  the  contrary,  he  cites  a  case  which  he 
considers  a  true  hypernephroma  developing  in  the  broad  ligament. 
This  patient  showed  changes  in  sex  characteristics.  Histologically,  the 
growth  was  identical  with  that  of  a  true  suprarenal  hypernephroma. 

The  tumors  have  been  observed  in  women  between  the  ages  of 
thirty  and  sixty  years.  Some  developed  after  the  menopause.  There 
is  no  definite  relation  to  pregnancy.  The  tumors  are  pedunculated  and 
often  lobulated.  They  vary  in  size  but  may  attain  the  dimensions  of 
an  adult  head.  Occasionally,  they  are  bilateral.  They  may  be  cystic. 
They  grow  extremely  rapidly  and  give  rise  to  implantation  growths 
and  to  general  metastases.  Consequently,  they  recur  after  removal. 
The  clinical  features  are  identical  with  those  of  other  malignant 
ovarian  tumors. 

The  Ovotestis  Tumors. — In  the  rare  cases  of  true  hermaphroditism, 
tumors  may  develop  from  the  testicular  elements  of  an  ovotestis. 


378  PELVIC  NEOPLASMS 

There  are  very  few  cases.  Pick  and  von  Schickele  both  describe 
ovaries  about  the  size  of  a  mandarin  orange  in  which,  sharply  de- 
marcated from  the  typical  ovarian  tissue,  were  lobulated  tumor  masses 
which  presented  the  microscopic  appearance  of  tubular  adenoma  of  the 
testis.  Polano  has  recently  described  a  case  of  true  hermaphroditism 
in  which  the  one  ovotestis  presented  the  typical  structure  of  a  terato- 
matous  chorio-epithelioma. 


GENERAL  SYMPTOMS  OF  OVARIAN  TUMORS 

In  addition  to  the  discussion  of  the  symptoms  that  we  have  made  in 
individual  tumors,  there  are  certain  general  statements  that  are  worthy 
of  emphasis. 

The  symptoms  of  ovarian  tumors  may  arise  from  disturbances  in 
ovarian  function,  may  be  caused  by  the  tumor  mass,  or  may  result  from 
complications. 

Interference  with  ovarian  function  may  cause  disturbances  of 
menstruation  and  sterility.  It  is  quite  remarkable  that  menstruation 
so  often  proceeds  normally  in  ovarian  tumors  of  considerable  size. 
Grouping  all  cases  of  ovarian  tumors  as  an  entity,  Martin  found  that 
menstruation  was  normal  in  75  per  cent  of  cases.  Lippert  found  the 
same  condition  in  43  per  cent  and  Wedekind  in  38  per  cent.  Moreover, 
it  appears  that  various  conditions,  as  irregularity,  variations  in  the 
amount  of  flow,  and  dysmenorrhea  may  result  solely  from  associated 
uterine  disease.  Amenorrhea  is  rather  rare  and  is  usually  due  to  the 
complete  destruction  of  ovarian  tissue.  It  may  follow  in  the  cachexia 
of  malignant  disease.  Very  exceptionally,  it  may  be  caused  by  a  uni- 
locular  benign  tumor  and  be  cured  by  removal  of  the  growth.  Martin 
found  amenorrhea  n  times  in  581  ovarian  tumors  of  all  types  and 
Lippert  19  times  in  635  cases.  Menorrhagia  is  a  common  symptom  in 
intraligamentous  tumors,  probably  from  interference  with  the  circula- 
tion. Bleeding  after  the  climacteric  occurs  often  in  malignant  disease 
and  occasionally  when  the  growth  is  benign.  It  may  be  due  to  torsion 
of  the  pedicle.  Precocious  menstruation  in  young  children  and  pre- 
mature sexual  development  may  disappear  after  the  removal  of  the 
tumor. 

Sterility  may  result  from  destruction  of  all  of  the  functionating 
ovarian  tissue,  or  from  mechanical  disturbances  from  the  size  of  the 
tumor  or  associated  inflammation.  There  are  many  cases  in  which 
pregnancy  resulted  after  a  considerable  period  of  sterility  following 
removal  of  the  tumor.  Yet  sterility  is  not  the  rule.  Any  slow-growing 
tumor  may  be  found  with  pregnancy,  even  when  the  growth  is  bilat- 
eral. On  the  contrary,  certain  signs  of  pregnancy  may  be  caused  by 
the  tumor.  They  are  chiefly  breast  changes  and  consist  of  hypertrophy 


TUMORS    OF    THE    OVARY  379 

and  tenderness  of  the  breast,  increase  in  the  pigment  of  the  mammary 
areola,  and  the  presence  of  colostrum. 

The  severity  of  the  symptoms  may  depend  upon  the  size  and  loca- 
tion of  the  tumor,  adhesion  formation,  and  the  individual  sensitiveness 
of  the  patient.  Tumors  may  develop  to  most  astonishing  size  without 
causing  symptoms.  Small  tumors  impacted  in  the  pelvis,  on  the  con- 
trary, cause  pain,  vesical  and  rectal  disturbances,  all  of  which  are 
aggravated  by  inflammation. 

Occasionally,  even  small,  freely  movable  tumors  may  cause  a  sense 
of  weight  in  the  pelvis  and  pain  in  the  back  and  sides  which  radiate 
down  the  legs.  Tumors  bound  down  by  adhesions  are  most  likely  to 
cause  symptoms.  Larger  abdominal  tumors  may  occasion  disturbances 
as  a  direct  result  of  their  size,  but  not  always  in  proportion  to  it.  Even 
mammoth  tumors  may  have  surprisingly  few  symptoms.  As  a  rule, 
however,  there  are  symptoms  from  pressure.  Pressure  on  the  stomach 
may  be  responsible  for  anorexia  and  nausea  and  vomiting.  Pressure 
on  the  intestine  may  cause  constipation  and  hemorrhoids.  Respiratory 
difficulties  follow  upward  displacement  of  the  diaphragm.  There  may 
be  edema  and  varicosities  of  the  abdominal  wall,  genitalia,  and  lower 
limbs  from  disturbances  of  the  venous  circulation.  Complete  prolapse 
may  be  the  sequence  of  ascites,  even  in  nullipara.  Inguinal,  femoral, 
and  umbilical  hernia  are  often  seen.  Bladder  disturbances,  including 
tenesmus  and  paradoxial  incontinence,  are  quite  common.  Compres- 
sion of  the  renal  veins  may  cause  albuminuria  and  a  decrease  in  the 
urinary  output.  If  not  too  far  advanced,  they  may  disappear  after 
operation.  Pressure  on  the  ureters  may  cause  dilatation  and  hydro- 
nephrosis.  We  have  seen  polyuria  reduced  by  removal  of  the  tumor. 
Many  have  reported  glycosuria  from  compression  of  the  pancreas. 
Bauereisen's  case  disappeared  after  ovariotomy  in  spite  of  three  years' 
duration. 

Ascites  is  rarely  caused  by  pressure  alone.  It  is  usually  found  with 
the  solid  and,  especially,  with  the  malignant  tumors.  It  may  be  due  to 
associated  renal  cardiac,  or  hepatic  changes. 

Complications  of  Ovarian  Tumors. — Ovarian  tumors  may  undergo 
a  number  of  complications.  Chief  of  these  are  torsion,  infarct  forma- 
tion and  infection.  We  will  discuss  only  torsion. 

TORSION. — Torsion  is  the  most  common  of  the  serious  complications. 
To  assume  clinical  dignity,  it  usually  requires  a  turn  of  180  degrees. 
Rokitansky,  in  1840,  called  attention  to  the  condition. 

It  is  difficult  to  determine  the  frequency  of  torsion.  Some  authors 
report  only  cases  giving  rise  to  severe  symptoms;  others  have  reported 
all  cases.  Its  frequency  is  probably  decreased  in  recent  years,  since 
cases  come  earlier  to  operation.  Mickwitz  reported  the  remarkable 
frequency  of  47  per  cent  in  Kuestner's  clinic,  due  to  the  fact  that  their 
patients  would  not  seek  treatment  until  driven  by  pain.  Other  reports 


380  PELVIC  NEOPLASMS 

give  percentages  varying  from  6  per  cent  (Martin)  to  30  per  cent 
(Jelpke).  Estor  recently  found  7.8  per  cent.  Wiener,  in  1915,  found 
pedicle  torsion  33  times  in  269  tumors  removed  in  the  Mount  Sinai 
Hospital  in  New  York  (12.26  per  cent). 

Torsion  occurs  most  frequently  in  tumors  of  medium  size  which 
alone  can  rotate  easily  in  the  abdominal  cavity.  The  very  large  tumors 
are  very  rarely  twisted.  The  cysts  must  be  free  for  torsion  to  occur. 
There  is  a  difference  of  opinion  concerning  the  length  of  the  pedicle. 
Estor  states  that  the  shorter  pedicles  are  more  likely  to  twist,  though 
Pfannenstiel  believes  this  occurs  more  often  in  the  long,  delicate  ones. 

Torsion  may  occur  in  any  type  of  tumor.  It  is  most  common  in 
cystadenoma  because  this  tumor  is  so  much  more  frequent.  It  occurs 
in  a  large  proportion  of  the  dermoids  and  fibroids  because  of  the 
greater  weight  of  the  tumor  (Aimes)  or  the  great  length  and  delicacy 
of  the  pedicle  (Pfannenstiel).  Probably  both  factors  are  partially 
responsible.  Torsion  is  unusual  in  malignant  tumors,  since  they  are 
early  held  down  by  inflammatory  or  neoplastic  adhesions. 

Torsion  occurs  most  frequently  in  right-sided  cysts.  These  tend  to 
rotate  like  the  hands  of  a  clock.  Tumors  of  the  left  side  rotate  in  the 
opposite  direction  (Kuestner's  law).  Torsion  occurs  in  this  typical 
manner  in  from  80  per  cent  to  85  per  cent  of  cases. 

Causes  of  Torsion. — Torsion  may  result  from  external  causes  or  internal 
factors  working  in  association. 

The  external  causes  are  due  to  sudden  disturbances  of  intra- 
abdominal  tension  caused  by  coughing,  vomiting,  or  other  sudden 
movements  of  the  body.  Physical  examination  of  the  patient  has  occa- 
sionally caused  it.  The  older  writers  state  that  laxity  of  the  abdominal 
walls  due  to  parity  favored  it,  yet  Aimes  found  it  frequently  in  nul- 
lipara. 

The  internal  factor  consists  in  changes  in  volume  of  neighboring 
organs.  The  filling  and  emptying  of  the  bladder,  intestinal  peristalsis, 
a  development  of  a  tumor  in  the  other  ovary,  changes  in  the  tumor 
itself,  the  development  of  different  densities  in  various  portions  of  a 
multilocular  cyst,  the  sudden  change  in  volume  due  to  spontaneous 
rupture  or  puncture,  the  changes  in  size  and  position  of  a  uterus  in 
pregnancy  and  the  puerperium,  and  the  removal  of  ascitic  fluid  may  be 
predisposing  factors  for  torsion. 

Other  various  interesting  theories  of  the  mechanics  of  torsion  fiave 
been  enumerated  by  Aimes,  yet  none  of  these  are  proved. 

The  uterus  may  be  twisted  along  with  the  tumor,  being  turned 
about  the  lower  segment  of  the  uterus.  It  is  especially  likely  to  occur 
in  children  and  in  pregnancy.  As  a  result  of  torsion,  the  tumor  may 
lie  on  the  side  of  the  abdomen  opposite  that  from  which  it  originated. 
The  number  of  turns  varies  from  half  a  turn  to  six  or  even  to  ten. 
Hollander  found  a  case  with  twenty-five  complete  turns.  The  tumor 


TUMORS    OF    THE    OVARY  381 

may  twist  entirely  away  from  its  stalk.  Twenty-five  per  cent  of  reported 
cases  had  two  complete  turns. 

The  resulting  lesions  depend  upon  the  rapidity  of  the  process  and 
the  number  of  turns.  Changes  occur  both  in  the  pedicle  and  the  cyst 
wall.  Thrombosis  is  usual  and  may  extend  even  through  the  broad 
ligaments  to  the  iliac  or  femoral  veins.  Similar  arterial  changes  may 
follow  the  venous  lesions,  even  in  incomplete  torsion.  Gangrene  and 
the  slough  of  the  tumor  may  follow  complete  torsion.  The  cyst  is 
markedly  congested  and  there  may  be  intracystic  hemorrhage  which 
may  cause  death.  The  cyst  walls  are  edematous  and  infiltrated  with 
blood,  and  marked  by  blue-black  hemorrhagic  infarcts.  Fibrinous 
deposits  cover  the  wall  and  form  points  for  adhesions.  Peritoneal 
irritation  is  the  rule,  yet  subsequent  infection  is  a  rare  complication  (5 
per  cent).  Adhesions  occur  in  50  per  cent  of  cases.  Ascites  develops 
rapidly,  and  varies  according  to  the  degree  and  intensity  of  the  con- 
gested phenomenon  of  a  clear  serous  fluid  to  almost  pure  blood. 

The  outcome  varies.  Death  may  ensue.  Spontaneous  detorsion 
is  a  possible  but  unusual  result.  Incomplete  torsion  may  cause  only 
superficial  lesions  with  adhesion  formation  and  the  acute  crisis  may 
pass,  or  recurrent  attacks  may  occur.  Even  gangrene  need  not  be 
fatal,  since  a  parasitic  circulation  may  develop.  As  a  result,  the  cyst 
may  continue  to  live,  occasionally  may  grow,  or  rarely  may  atrophy 
and  be  the  seat  of  sclerotic  or  fatty  degeneration  or  calcification.  These 
favorable  results  cannot  often  be  expected.  There  may  be  a  sudden 
rupture  of  the  vessels  of  the  pedicle  and  a  veritable  peritoneal  inunda- 
tion. 

Symptoms  of  Torsion. — These,  like  the  pathological  lesions,  vary  with 
the  degree  and  rapidity  of  the  twisting.  Sudden  torsion  is  supposed  to 
occur  in  28  per  cent  to  30  per  cent  of  cases.  There  is  intense  pain  and 
peritoneal  reaction.  The  pain  may  cause  syncope,  pallor,  shock,  a 
rapid,  small  pulse,  and  cold  sweats.  The  peritoneal  reaction  -is  marked 
by  abdominal  distention.  There  may  be  dyspnea,  nausea,  and  vomit- 
ing, or  sometimes  constipation.  Paralytic  ileus  may  be  a  feature. 
True  obstruction  may  occur  when  the  growth  has  been  accompanied  by 
adhesions. 

The  temperature  varies.  Low  at  first,  it  arises  as  a  result  of 
absorption  of  blood  or  peritoneal  infection.  Metrorrhagia  is  impor- 
tant, since  it  may  direct  attention  to  the  pelvis  in  an  acute  abdominal 
crisis  for  which  no  cause  may  be  apparent.  Rather  infrequently,  the 
patient  is  aware  of  a  sense  of  displacement  of  an  abdominal  mass  felt 
at  the  beginning  of  symptoms. 

The  mild  subacute  or  chronic  torsion  occurs  in  about  60  per  cent 
of  cases.  It  is  more  easily  recognized  and  the  signs  are  milder  and  the 
patient  is  less  ill.  The  pain  is  less  intense  and  may  reappear  at  irreg- 


382  PELVIC  NEOPLASMS 

ular  intervals  or  at  each  menstruation.     The  abdomen  may  remain 
tender,  or  may  be  swollen  for  several  days  after  each  attack. 

Latent  torsion  occurs  without  symptoms  in  approximately  10  per 
cent  of  cases.  It  may  be  recognized  only  when  the  condition  is  found 
at  operation.  Gourden  described  a  case  in  which  the  cyst  was  parasitic, 
having  been  detached. 


LITERATURE 

AIMES.    Progres  med.     1920.    45:483. 

AMANN.     Miinchen.  med.  Wchnschr.     1905.     52:  2414. 

BARRETT.     Surg.,  Gynec.  &  Obst.     1913.     16:  28. 

EISENSTADTER.     Monatschrft.  f.  Geburtsh.     1921.     4:  360. 

FRANK.    Am.  J.  Obst.     1907.    55  :  438. 

FRANKL.    Arch.  f.  Gynak.     1920.     113:29. 

Zentralbl.  f.  Gynak.     1912     36:  1761. 

Zentralbl.  f.  Gynak.     1920.    44:  373. 

GEBHARD.    Pathologische  Anatomic  der  weiblichen  Sexualorgane.     P.  364. 
GOODALL.     Surg.,  Gynec.  &  Obst.     1920.     30:  249. 
GOTTSCHALK.     Arch.  f.  Gynak.     1899.     59:  676. 
HARRIS.   .Surg.,  Gynec.  &  Obst.     1917.    24:604. 
HINES.    Lancet-Clinic.     1916.     115:277. 
INGIER.    Arch.  f.  Gynak.     1907.    83:  545. 
KROEMER.    Veit's  Handbuch  der  Gyhakologie.    4:  206. 
KRUKENBERG.    Arch.  f.  Gynak.     1895.     50:  286. 
LEY.    Proc.  Roy.  Soc.  Med.    1919.     13:  95. 
LUDWIG.    Wien.  klin.  Wchnschr.     1905.     18:  715. 
MARTIN'S  Handb.  d.  Gynak.    2 :  487. 

MASSABUAU  AND  ETIENNE.    Rev.  de  gynec.  et  de  chir.  abd.    1913.    20:225. 
NECK  AND  NAUVEUCK.     Monatschr.  f.  Geburtsh.     1902.     15:  797. 
NORRIS.    Am.  J.  Obst.     1913.    68:  420. 
NOVAK.     Zeigler's  Beitr.     1909.     45:  i. 

PFANNENSTIEL.    Veit's  Handbuch  der  Gynakologie.    4:  428:  443. 
RABINOWITSCH.     Inaugural  Dissertation.     Giesson,  1910. 
SCHLAGENHAUFER.     Monatschr.  f.  Geburtsh.     1902.     15:485. 
STONE.     Surg.,  Gynec.  &  Obst.     1916.    22:407. 
WALTHARD.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1903.    49:  233. 
WIENER.    Am.  J.  Obst.     1915.    72:  208. 
WILLIAMSON  AND  BARRIE.     J.   Obst.   &  Gynec.   British   Empire.      1911. 

20:  211. 
WILMS.     Monatschr.  f .  Geburtsh.    9 :  585. 

Martin's  Handbuch  der  Gynakologie.    2:  579. 


CHAPTER    XIII 

TUMORS  OF  THE  BROAD  LIGAMENT,  THE  ROUND  LIGAMENT,  AND  THE 

FALLOPIAN  TUBES 

Tumors  of  the  round  ligament — Historical — Etiology — Age — Types — Location  and  size  of 
tumors — Microscopic  picture — Symptoms  and  clinical  course — Diagnosis — Treatment 
— Prognosis — Tumors  of  the  ovarian  ligament — Tumors  of  the  mesosalpinx — Cysts  of 
fimbria  ovarica  —  Of  para-ovarium  —  Hydatid  of  Morgagni  —  Of  accessory  tubes  — 
Fibroids  of  the  broad  ligament — Fibromyoma — Age — Appearance  and  form — Symp- 
toms— Growths — Degenerations — Lipoma — Sarcoma — Treatment  of  solid  tumors  of 
the  broad  ligament — Tumors  of  the  fallopian  tubes — Classification  (Polyps — Papil- 
loma) — Treatment — Malignant  epithelial  tumors  —  Carcinoma  —  Frequency  —  Age  — 
Classification — Symptoms — Ascites — Diagnosis — Prognosis  —  Treatment  —  Secondary 
tubal  carcinoma  —  Benign  tumors  arising  from  mesoblast  tissue  —  Enchondroma  — 
Lipoma — Lymphangioma — -Fibroma — Adenomyoma — Malignant — Sarcoma — Symptoms 
Mixed  tumors — Embryological  tumors — Teratoma  and  dermoids — Frequency — Chorio- 
epithelioma. 


TUMORS  OF  THE  BROAD  LIGAMENT 

Included  under  this  heading  are  the  tumors  which  occur  in  the 
round,  ovarian,  and  broad  ligaments,  as  well  as  those  which  lie  in  the 
mesosalpinx,  but  which  do  not  develop  from  the  tubes. 

TUMORS  OF  THE  ROUND  LIGAMENT 

Historical. — While  a  few  scattered  cases  were  noted  by  pathol- 
ogists,  the  interest  in  this  group  of  tumors  was  aroused  in  1865  when 
Spencer  Wells  described  two  tumors  of  this  structure  which  he  found 
at  operation.  From  this  time  on,  isolated  reports  appeared  in  the 
literature  so  that  Sanger,  in  1882,  was  able  to  present  his  study  based 
on  his  own  cases  and  12  which  had  been  previously  reported.  This 
article  forms  the  groundwork  of  the  subject.  In  1896,  Cullen  reported 
the  first  adenomyoma  noted  in  the  round  ligament  and,  in  1903, 
Emanuel  was  able  to  collect  76  tumors  of  the  round  ligament  from  the 
literature.  Taussig,  in  1914,  increased  the  number  to  141,  since  when 
there  has  been  no  further  compilation.  In  a  casual  review,  we  have  found  9 
isolated  case  reports  to  which  we  would  add  3  unpublished  cases  occur- 
ring in  our  service.  The  group  consists  of  5  fibroids,  i  fibromyoma,  4 
adenomyoma  and  I  sarcoma. 

383 


384  PELVIC  NEOPLASMS 

They  are  reported  by  Iraeta,  in  1917;  Moench,  Ward,  and  Cirio,  in 
1918;  Brown,  and  Walther,  1919;  Cullen,  and  Durand,  1920.  Two  of 
our  cases  were  nbromyomata  and  one  adenomyoma. 

Types  of  Tumor  Found. — In  a  review  of  the  subject  of  tumors  of 
the  round  ligament,  one  is  struck  by  the  variety  of  neoplasms  which 
may  occur  in  this  simple  structure,  although  their  number  is  not  great 
when  compared  with  tumors  in  other  parts  of  the  body.  It  is  well  to 
remember,  as  Krusen  emphasizes,  that  the  round  ligament  properly 
must  be  considered  as  a  part  of  the  uterus,  and  that  growths  which  are 
seen  in  the  uterus  may  be  seen  also  in  the  round  ligament.  We  will 
follow  Emanuel's  suggestion  and  not  consider  hydrocele  of  the  round 
ligament,  since  this  is  not  really  a  tumor  of  the  round  ligament  but  is  a 
collection  of  fluid  in  the  spaces  of  the  tunica  vaginalis  which  is  open  in 
the  embryo,  but  which  later  becomes  closed  off.  These  accumulations 
have  only  a  slight  connection  with  the  round  ligament  and  are  not 
within  its  substance,  as  they  must  be  to  be  true  tumors.  Lewis,  in  1903, 
states  that  the  following  tumors  have  been  recorded:  fibroma,  including 
fibromyoma  (which  is  most  common);  fibrosarcoma ;  adenomyoma;  cysts 
(simple  and  dermoid)  ;  and  lipoma.  Hematoma  and  abscess  have  been 
recorded,  but  these  are  not  neoplasms.  Two  cases  of  carcinoma  are 
present  in  the  literature  which  are  of  considerable  interest,  since  nor- 
mally the  round  ligaments  do  not  contain  glands.  The  incidence  of  the 
more  frequent  of  the  neoplasms  is  given  in  Taussig's  table  where  he 
records  79  fibromyoma;  30  adenomyoma;  and  6  sarcoma. 

Etiology. — The  etiology  is  not  known.  Much  work  has  been  done 
to  determine  the  histogenesis  of  the  various  tumors  included  in  the 
general  group.  Fibroma  and  fibromyoma  have  the  same  origin  as 
similar  growths  in  the  uterus.  The  suggestion  of  Handley  that  fibroids 
might  arise  from  accessory  fallopian  tubes,  which  Kauffmann  says 
occur  so  frequently,  has  not  been  well  received.  The  etiology  of 
adenomyoma  has  already  been  discussed  (p.  163).  Cysts  are  usually 
believed  to  have  developed  from  the  peritoneum.  This  view  was  first 
advanced  by  Opitz,  and  has  been  accepted  by  Emanuel,  Robert  Meyer, 
Foederl,  and  Vassmer.  Lewis  believes  that  the  carcinomata  which 
have  been  found  in  the  ligament  are  due  to  misplaced  embryological 
cells  (Cohnheim's  theory)  while  Dubar  considers  that  his  case  devel- 
oped from  embryologic  remnants  of  the  wolffian  body,  a  theory  which 
is  accepted  by  Opitz.  Emanuel  feels  that  it  is  more  likely  that  they 
developed  from  unrecognized  extensions  from  adenomyomata. 

Nothing  is  known  as  to  the  predisposing  causes.  Lewis  points  out 
that  pregnancy  does  not  seem  to  have  any  etiological  bearing.  Nor 
has  he  found  anything  to  support  the  older  view  of  Sanger  that  traction 
of  a  displaced  uterus  may  be  a  causative  role.  A  review  of  the  liter- 
ature does  not  indicate  that  trauma  plays  any  part  in  the  origin  of  the 
tumor. 


TUMORS   OF   THE   BROAD   LIGAMENT  385 

Age. — Taussig  found  that  the  majority  of  fibroids  occurred  in 
patients  between  thirty  and  fifty  years  of  age,  agreeing  rather  closely 
with  Spencer's  earlier  statement  that  tumors  of  this  type  were  more 
common  after  forty.  Cullen  says  that  the  adenomyomata  usually  occur 
during  the  menstrual  age.  Taussig  found  that  the  sarcomata  were 
described  between  the  ages  of  twenty-two  and  forty-four.  The  young- 
est tumor  in  this  location  was  a  rhabdomyoma  found  by  Aichel  in  a 
newly  born  child,  while  the  oldest  case  was  a  fibroma  in  a  woman  of 
seventy-six,  reported  by  Winckel. 

Location  of  Growth. — Tumors  may  spring  from  any  portion  of  the 
round  ligament,  and,  in  general,  may  be  either  intra-abdominal  or 
extra-abdominal.  The  latter  are  more  common.  Emanuel,  in  his 
analysis  of  80  cases,  found  the  distribution  as  follows : 

Cases 
Intra-abdominal 20 

Extra-abdominal  (inguinal  canal  or  labial  folds) 60 

Nobesky  found  15  intra-abdominal  tumors  and  38  extra-abdominal. 
Taussig  reports  18  intra-abdominal  and  30  extra-abdominal. 

The  intra-abdominal  tumors  arise  most  frequently  from  the  portion  of 
the  round  ligament  portion  which  is  nearest  the  uterus.  They  usually  grow 
outward  into  the  peritoneal  cavity  so  that  they  present  the  appearance  of 
a  pedunculated  tumor  attached  to  the  ligament.  They  may,  however, 
grow  down  into  the  broad  ligament.  If  situated  near  the  internal  ring, 
they  are  very  likely  to  grow  subperitoneally.  Lewis  found,  in  his 
review  of  the  extra-abdominal  cases,  that  the  tumors  might  be  situated 
directly  over  the  external  orifice  of  the  inguinal  canal,  at  the  upper 
extremity  of  the  labia  majus,  or  above  or  below  the  labia  majus,  where 
normally  no  tissue  of  the  round  ligament  can  be  found. 

There  is  no  agreement  as  to  which  side  is  more  commonly  involved. 
They  may  be  found  on  either  the  right  or  left  round  ligament.  Eman- 
uel found  more  than  three  times  as  many  on  the  right  side  as  on  the 
left.  Spencer,  in  1904,  found  9  cases  on  the  right  side  and  5  on  the 
left,  as  well  as  I  case  which  presented  a  tumor  in  each  ligament  and  I 
which  had  two  tumors  in  one  ligament.  Krusen,  in  1908,  stated  that 
most  of  the  growths  occurred  on  the  right  side  and  in  multipara. 
Muhlen,  in  1910,  collected  76  cases  and  found  that  the  majority  were 
on  the  right  side.  In  1914,  Taussig  found  that  the  tumors  collected 
and  published,  since  Emanuel's  tabulation,  were  20  on  the  right  side 
and  17  on  the  left. 

Size  of  Tumor. — The  size  of  the  tumor  varies  greatly  and  may 
range  from  that  of  a  small  kernel  to  that  of  an  infant's  head  or  larger. 
Lewis  found  that  the  tumors  in  the  inguinal  canal  were  much  smaller 
than  those  in  the  labia  majus.  Taussig  reported  that,  as  a  whole,  the 


3  86  PELVIC   NEOPLASMS 

extraperitoneal  tumors  were  larger  than  the  intraperitoneal.  Some  of 
the  larger  tumors  recently  reported  are  as  follows:  Moench,  1918,  a 
sarcoma  the  size  of  a  grapefruit;  Walther,  1919,  a  fibromyoma  measur- 
ing 22  X  17  X  13  centimeters  and  weighing  2  kilograms;  Ward,  1918, 
a  fibroid  46X48  centimeters,  which  weighed  3  pounds  8  ounces; 
Spencer's  tumor,  in  1904,  found  in  a  virgin  of  twenty-four,  weighed  6 
pounds. 

The  form  varies  considerably.  The  fibroids  and  fibromyomata  are 
usually  round  or  oval;  occasionally,  they  are  multilocular.  Owing  to 
the  frequency  of  cystic  and  telangiectatic  changes,  a  certain  proportion 
have  a  semisolid  or  even  fluctuating  consistency.  Ordinarily,  however, 
they  are  firm.  In  19  cases,  Taussig  found  that  there  was  only  a  thin 
shell  of  fibromuscular  tissue  surrounding  a  cyst.  Three  of  these  con- 
tained blood  and  were  classed  as  hematoma.  Occasionally,  these  cysts 
were  multilocular.  The  fibroids  may  be  pedunculated  or  sessile,  intra- 
peritoneal, or  subperitoneal.  One  half  of  the  cases  collected  by  Spencer 
were  associated  with  uterine  fibroids.  The  pedicle  may  be  formed  by 
the  ligament  itself,  which  has  hypertrophied,  or  there  may  be  a  sep- 
arate pedicle  attaching  the  tumor  to  the  ligament.  Torsion  of  this 
pedicle  may  occur.  The  outline  of  the  tumors  which  are  situated  extra- 
abdominally  varies  according  to  their  situation,  as  has  been  discussed 
in  fibroma  of  the  labia  (page  3.) 

Adenomyoma  may  occur  as  large  nodules  containing  cystlike  spaces 
which  may  contain  chocolate-colored  fluid  or  present  brown  or  yellow 
pigmented  areas. 

The  sarcomata  are  small  and  are  situated  most  frequently  extra- 
abdominally. 

The  lipoma  may  be  globular  or  elliptical  and  may  present  a  smooth, 
or  lobulated  surface.  Their  consistency  varies  on  palpation,  depending 
upon  the  degree  of  tension  in  the  tumor.  Usually  firm,  they  may 
be  soft,  elastic,  or  fluctuating.  The  lipoma  may  be  multiple,  or  single; 
in  the  former  instance,  the  growths  are  independent  of  each  other. 

Microscopic  Picture. — The  histology  of  the  tumors  of  the  round 
ligament  is  identical  with  that  of  the  same  tumors  in  other  situations 
in  the  body.  They  present,  moreover,  various  degenerations  which 
have  been  described  for  the  uterine  fibroids,  namely,  lymphangiectatic, 
myxomatous,  calcereous,  hyaline,  and  malignant  changes. 

Symptoms  and  Clinical  Course. — The  tumors  of  the  round  ligament 
usually  grow  slowly  and  consequently  may  be  followed  for  a  consider- 
able period  without  marked  increase  in  size.  Cullen  reported  a  case  of 
adenomyoma  which  had  been  present  for  eight  years  and  Blumer 
recorded  one  which  had  been  known  to  be  present  for  twenty-two 
years.  Maly  described  a  myxosarcoma  which  had  existed  for  sixteen 
years  and  Taussig  one  which  had  been  followed  for  two  years. 

The  symptoms  depend  upon  the  situation  of  the  tumor.     If  located 


TUMORS   OF   THE    BROAD   LIGAMENT  387 

intra-abdominally,  the  neoplasm  may  occasion  little  or  no  incon- 
venience. As  the  growth  increases  in  size,  pain  may  follow  from  pres- 
sure. At  first,  there  is  discomfort  in  the  lower  abdomen  which  pres- 
ently changes  to  pain  which  may  radiate  down  the  legs  and  seriously 
interfere  with  locomotion.  Pressure  symptoms  from  the  bladder  and 
the  ureter  have  been  reported.  The  symptoms  are  usually  aggravated 
during  menstruation.  Tumors  in  this  situation  do  not  prevent  preg- 
nancy nor  cause  abortion  (Spencer),  although  pregnancy  usually  stim- 
ulates them  to  active  growth  (Taussig). 

The  symptoms  of  the  extra-abdominal  forms  have  been  considered 
under  fibroma  of  the  vulva  (page  i). 

Diagnosis. — The  diagnosis  of  tumors  of  the  round  ligament  may  be 
difficult.  Tumors  developing  on  the  intra-abdominal  portion  of  the 
ligament  are  usually  confused  with  pedunculated  fibroids  of  the  uterus, 
tumors  of  the  broad  ligament,  ovarian  or  para-ovarian  growths,  or  even 
with  pus  tubes.  As  has  been  stated,  under  the  section  of  fibroids  of  the 
vulva,  neoplasms  of  the  extra-abdominal  portion  of  the  ligament  may 
be  confounded  with  incarcerated  hernias  or  enlargement  of  the  lymph 
glands.  The  painful  phenomena  which  occur  at  time  of  the  menstrual 
periods,  while  fairly  characteristic  of  fibromyoma  of  the  round  liga- 
ment, are  not  pathognomonic  because  ovarian  tumors,  or  ovarian 
hernia,  may  give  the  same  symptoms. 

DIFFERENTIAL  DIAGNOSIS. — The  differential  diagnosis  between  the  dif- 
ferent varieties  of  the  solid  tumors  of  the  ligament  can  be  made  only 
by  microscopic  examination  of  tissue. 

Treatment. — The  treatment  of  these  tumors  is  removal,  which 
should  be  done  as  early  as  the  tumor  is  recognized. 

Prognosis. — The  prognosis  depends  here,  as  in  all  cases,  upon  the 
histologic  structure  of  the  neoplasm.  Relief  of  symptoms  usually  fol- 
lows removal  of  these  tumors.  We  must  keep  in  mind  that  tumors  in 
this  region,  though  benign  at  first,  may  undergo  malignant  degenera- 
tion and  thereby  render  the  malignant  process  more  serious.  Sarco- 
mata are  rare  and  we  find  record  of  only  7  where  the  diagnosis  is  def- 
inite. Without  exception,  they  were  slow-growing  and  but  slightly 
malignant  clinically.  None  of  them  had  given  rise  to  metastases,  nor 
is  there  record  of  recurrence  after  operation. 

There  are  only  two  deaths  following  operation  for  sarcomata. 
The  first  case  was  recorded  thirty  years  ago  by  Sanger,  and  was 
a  fibrosarcoma  in  which  the  incorrect  diagnosis  aided  in  the  unfor- 
tunate result.  The  condition  was  believed  to  be  a  hernia  and  the 
patient  wore  a  truss  for  four  years,  at  the  end  of  which  time  she 
complained  of  the  utmost  pain  and  a  tumor  the  size  of  a  child's 
head.  The  growth  was  now  considered  a  fibrocystoma  but  operation 
revealed  the  presence  of  a  fibrosarcoma.  The  details  of  the  death  of 
Moench's  case  are  not  given,  other  than  that  it  followed  eight  weeks 


388  PELVIC  NEOPLASMS 

after  a  sarcomatous  growth  the  size  of  a  grapefruit  which  clinically  was 
felt  to  be  extremely  malignant  but  which  was  thought  to  be  completely 
removed. 

Para-ovarian  Tumors. — In  the  female,  the  para-ovarian,  or  organ 
of  Rosenmuller,  represents  the  fetal  remains  of  the  mesonephros,  and 
is  situated  between  the  leaves  of  the  broad  ligament,  near  the  tube  and 
ovary.  It  consists  of  a  main  channel  (the  duct  of  Gartner)  and  eight  to 
ten  lateral  branches,  or  vertical  tubules,  which  converge  in  the  direc- 
tion of  the  hilum  of  the  ovary.  The  duct  of  Gartner  usually  ends 
blindly  between  the  two  layers  of  the  broad  ligament;  occasionally,  it  is 
continued  downward  in  the  wall  of  the  uterus  and  vaginal  fornix  and 
may  give  rise  to  cysts  in  these  regions.  The  lateral  end  of  the  duct 
is  converted  into  a  blind  pouch  which  frequently  becomes  enlarged  and 
cystic  and  is  known  as  the  hydatid  of  Morgagni  (page  390).  The  para- 
ovarian  reaches  its  highest  state  of  development  in  sexual  life,  although 
its  exact  function  is  unknown;  various  experimental  data  has  been 
accumulated  which  tends  to  support  the  view  that  the  structure  fur- 
nishes an  internal  secretion. 

Para-ovarian  Cysts. — Para-ovarian  cysts  develop  from  the  vertical 
tubule  and  are  the  most  common  tumor  of  this  structure.  As  small 
structures  they  are  very  frequent  and  are  usually  noted  during  opera- 
tions for  other  conditions.  Larger  sacs  are  found  less  frequently. 
According  to  Olshausen,  they  were  found  in  11.3  per  cent  of  his  ovario- 
and  para-ovariotomies.  Veit  fourid  the  condition  of  n.8  per  cent  of  his 
material,  Schauta  9.1  per  cent,  Lippert  6.7  per  cent,  Martin  14.4  per 
cent.  Kelly,  in  410  cases  of  cystic  tumors  of  the  ovaries  of  all  kinds, 
found  that  para-ovarian  cysts  occurred  in  about  12  per  cent.  As  a  rule, 
para-ovarian  tumors  occur  about  middle  life.  According  to  Kelly,  the 
average  age  was  thirty-nine  years.  As  before  mentioned,  the  cysts  are 
usually  small,  although  they  may  reach  a  considerable  size,  as  is  shown 
by  Kiimmeirs  case  of  forty-two  pounds,  Nagel's  tumor  containing 
thirty-three  liters  of  fluid,  and  Mayo  Robson's  of  one  hundred  and  five 
pounds. 

Para-ovarian  cysts  are  generally  unilocular.  In  the  smaller  cysts, 
however,  two  or  more  loculae  may  occur.  The  larger  cysts  are  almost 
always  unilocular.  The  tumors  may  be  bilateral,  (small  cysts),  but  the 
larger  cysts  are  nearly  always  unilateral.  The  cyst  wall  is  usually  flac- 
cid, in  marked  contrast  to  that  of  ovarian  tumors. 

Para-ovarian  cysts  originate  between  the  folds  of  the  broad  liga- 
ment, and  the  peritoneal  coat  is  freely  movable  over  the  tumor.  As 
the  cyst  grows,  it  presents  either  as  a  pedunculated  tumor  which  lies 
free  in  the  abdominal  cavity,  or  one  which  burrows  down  between  the 
layers  of  the  broad  ligament  and  develops  extraperitoneally  in  the 
abdomen.  The  latter  type  usually  displaces  the  uterus  from  the  pelvis. 
The  cysts  are  pearlish  gray,  or  pinkish  in  color,  and  histologically  are 


TUMORS   OF   THE   BROAD   LIGAMENT  389 

composed  of  three  layers :  (a)  a  serous  coat  derived  from  the  broad 
ligament;  (b)  a  middle  layer  of  fibrous  tissue  in  which  a  few  muscle 
bundles  are  scattered;  and  (c)  an  inner  layer  of  cylindrical,  often 
ciliated,  epithelium.  The  form  of  the  epithelium  depends  upon  the 
amount  of  pressure  exerted  by  the  fluid;  thus  the  epithelium  may  be 
high  columnar  or  else  flattened  and  containing  desquamated  and 
degenerated  cells.  Papillary  fibro-epithelial  growths  from  the  cyst  wall 
are  often  seen.  The  cyst  contents  are  usually  thin  and  opalescent,  but 
may  be  changed  to  a  thick  brown  color  as  a  result  of  hemorrhage,  or 
fatty  degeneration  usually  caused  by  torsion  of  the  pedicle.  The  rela- 
tions of  the  tube  and  ovary  to  the  cyst  are  characteristic.  The  tube  is 
drawn  out  and  arched  up  over  the  upper  surface  of  the  tumor  and  its 
fimbriated  end  is  adherent  to  the  cyst.  The  ovary  is  found  as  a  small 
flattened  prominence  on  the  under  or  anterior  surface  of  the  cyst  wall. 
The  tube  may  be  stretched  to  enormous  length.  Payer  cites  a  case  in 
which  it  measured  76  centimeters.  When  the  cyst  develops  directly 
under  the  tube,  the  fimbria  may  be  so  stretched  and  separated  from  the 
ovary  that  it  may  be  definitely  said  to  cause  sterility. 

SYMPTOMS. — Symptoms  usually  develop  only  when  the  tumor  has 
attained  considerable  size  unless  complications  have  ensued.  They  are 
not  likely  to  occur  early  when  the  growth  is  pedunculated  and  movable, 
since  this  form  early  leaves  the  pelvis  and  rides  free  in  the  lower 
abdomen.  Pressure  symptoms  may  develop  early  when  the  tumor  is 
sessile  and  grows  between  the  leaves  of  the  broad  ligament.  The 
patient  then  complains  of  a  sense  of  weight  and  fullness  in  the  pelvis, 
pain  in  the  hips  and  thighs,  and  difficulty  in  micturition  and  defecation. 
Yet  symptoms  result  more  frequently  from  torsion  which,  unfor- 
tunately, is  very  common.  The  symptoms  following  torsion  are 
identical  with  those  of  ovarian  cysts,  namely,  acute  lower  abdominal 
pain  and  sudden  enlargement  of  the  tumor.  The  picture  varies,  depend- 
ing upon  the  completeness  of  the  strangulation  and  the  time  when  it 
occurred,  and  varies  from  simple  congestion  to  gangrene.  Adhesions 
to  the  intestine  often  result  and  are  the  cause  of  symptoms.  The  cyst 
may  become  infected  through  the  bowel  wall  which  is  adherent  to  the 
gangrenous  cyst.  Adhesions  between  the  cyst  and  small  bowel  may 
readily  cause  intestinal  obstruction. 

DIAGNOSIS. — The  symptomatology  of  para-ovarian  cysts  is  by  no  means 
characteristic.  The  diagnosis  is  not  often  made  until  the  abdomen  is 
opened  because  para-ovarian  cysts  cannot  be  differentiated  from  cysts 
of  the  ovary  unless  the  ovary  itself  can  be  felt  distinctly  apart  from  the 
smooth  semifluctuant  tumor. 

TREATMENT. — Cysts  of  appreciable  size  should  be  removed  as  soon 
as  possible,  since  their  early  recognition  permits  conservative  surgery. 
Salpingo-oophorectomy  is  seldom  necessary  in  moderate-sized  cysts, 
either  when  the  tumor  hangs  free  or  is  imbedded  in  the  broad  ligament. 


390  PELVIC  NEOPLASMS 

Yet  proper  peritonealization  is  the  secret  of  ultimate  good  results  and 
one  should  never  leave  raw  surfaces  in  the  desire  to  do  conservative 
surgery.  Early  operation  before  the  advent  of  torsion  alone  promises 
the  possibility  of  successful  conservative  work,  since  radical  measures 
are  often  indicated  in  the  presence  of  the  sequelae  of  torsion  of  the 
stalk. 

PROGNOSIS. — The  prognosis  is  good  in  uncomplicated  cases.  The  tumor 
does  not  return.  If  all  raw  peritoneal  surfaces  are  turned  in,  there 
should  be  no  adhesions. 

Para-ovarian  Tumors  Other  Than  Cysts. — Tumors  which  fall  into 
this  classification  are  very  rarely  seen.  They  are  counted  as  the  most 
infrequent  tumors  in  pelvic  pathology.  Besides  the  papillary  cysts 
which  have  just  been  mentioned,  there  have  been  reported  a  few  cases 
of  a  grapelike  cystoma  (Werth).  Adenomyoma  and  fibre-adenoma 
have  been  described  by  Pick  and  Bennet.  Carcinoma  of  the  para- 
ovarium  have  been  observed  by  Sanger,  Werth,  R.  Meyer,  and  Schott- 
laender.  The  latter's  case  presented  as  a  metastatic  growth  from  a 
uterine  carcinoma  which  was  implanted  in  the  wall  of  the  para-ovarian 
cyst.  Tabney  reported  a  case  which  presented  cancerous  growths  in 
both  para-ovaria  which  were  metastases  from  a  primary  carcinoma  of 
the  stomach.  Werth  has  described  a  primary  adenosarcoma. 

Cysts  of  the  Hydatid  of  Morgagni. — The  hydatids  of  Morgagni  are 
cystic  dilatations  of  the  blind  end  of  Gartner's  duct.  They  are  occa- 
sionally converted  into  small  cysts,  pedunculated  and  translucent,  which 
contain  a  thin  serous  fluid.  They  are  regarded  as  retention  cysts  and 
are  usually  attached  by  long,  slender  pedicles  to  the  firribria  of  the  tube 
or  the  peritoneum  of  the  mesosalpinx  immediately  beneath  them.  They 
are  seldom  larger  than  a  centimeter  in  size,  although  rarely  they  attain 
the  dimensions  of  a  walnut.  They  have  no  pathologic  significance, 
unless  there  is  torsion  of  the  pedicle  when  they  may  cause  symptoms. 
We  have  seen  a  case  which  simulated  an  ectopic  pregnancy. 

Cysts  from  Accessory  Fallopian  Tubes  or  Ostia. — Cysts  not  infre- 
quently arise  from  inclusions  of  occluded  accessory  fallopian  tubes. 
The  tubes  presenting  these  growths  are  small  and  poorly  developed 
yet  may  reproduce  in  their  structure  the  essential  histologic  elements 
of  a  normal  tube.  They  may  be  provided  with  a  patent  ostium  which 
opens  into  the  peritoneal  cavity,  or  the  ostium  may  be  blind.  There 
is  considerable  discussion  as  to  the  histogenesis.  Hydrosalpinx  of 
an  accessory  fallopian  tube  was  first  described  by  Kossmann.  Hand- 
ley  demonstrated  a  broad  ligament  cyst  which  had  sprung  from  an 
accessory  tube.  These  tumors  may  grow  to  considerable  size.  Col- 
lingsworth,  in  1903,  removed  at  operation  a  hydrosalpinx  of  an  acces- 
sory tube  which  measured  three  inches  in  diameter.  It  had  caused 
much  pain. 


Solid  Tumors  of  the  Broad  Ligament. — In  addition  to  the  new 
growths  which  arise  from  the  embryonal  elements  in  the  broad  liga- 
ments, and  are  cystic  in  character,  there  are  a  group  of  solid  tumors 
of  mesodermic  origin.  For  the  most  part,  these  are  secondary  from 
the  extension  of  primary  tumors  from  the  round  ligament,  uterus  and 
ovaries  into  the  substance  of  the  broad  ligament.  These  have  been 
discussed  in  their  proper  classification. 

The  primary  solid  tumors  of  the  broad  ligament  include  fibroids, 
lipomata,  and  sarcomata. 

Solid  tumors  may  develop  in  the  broad  ligament  as  a  primary 
process,  or  may  grow  into  it  by  extension  from  other  structures.  The 
latter  have  been  considered  under' their  proper  headings.  The  primary 
tumors  consist  of  fibroids,  lipoma,  sarcoma,  and  dermoids. 

The  tumors  which  develop  as  primary  processes  may  be  located 
anywhere  in  the  broad  ligament.  Those  which  develop  in  the  upper 
portion  come  to  occupy  a  position  in  the  pelvis  similar  to  tumors  of  the 
uterine  body,  the  round  ligament,  and  ovaries  from  which  they  may 
be  distinguished  with  difficulty  before  operation.  The  neoplasms  which 
develop  near  the  base  of  the  broad  ligament  usually  grow  downward 
and  eventually  tend  to  block  the  pelvis. 

Fibromyoma. — The  majority  of  these  tumors  lying  between  the 
folds  of  the  broad  ligament  are  extensions  from  uterine  fibroids,  yet 
this  class  never  separate  from  the  uterine  wall,  as  may  pedunculated 
subserous  growths,  and  present  as  free  structures.  Careful  examina- 
tion always  discloses  connecting  muscle  and  fibrous  bands.  A  smaller 
group  of  tumors  may  develop  as  independent  structures,  arising  from 
fibromuscular  bands  in  the  subserous  cellular  space,  since  the  same 
factors  which  produce  fibroids  in  the  uterus  exert  their  influence  in 
the  broad  ligament.  Fibromyoma  primary  in  the  broad  ligament  are 
seldom  seen  when  the  uterus  is  perfectly  normal.  The  very  great 
majority  occur  when  the  uterus  is  also  the  seat  of  fibroid  changes. 
The  first  case  was  reported  by  Burnham  in  1867.  Since  then,  there 
have  appeared  a  few  isolated  reports  so  that,  in  1907,  Vance  was  able 
to  collect  only  16  broad  ligament  fibroids  which  were  deemed  to  be 
independent  of  uterine  growth,  12  of  which  were  reported  in  America. 
Doran,  in  a  later  review,  compiled  32  cases. 

Age. — The  age  of  the  patients  in  Vance's  series  ranged  from 
twenty-two  to  fifty-six  years.  Of  these,  three  were  under  thirty  and 
two  over  fifty  years.  Six  of  Doran's  cases  were  under  thirty  and  six 
above  fifty  years.  From  these  figures  we  see  that  most  of  the  cases 
occur  between  thirty  and  fifty  years. 

Appearance  and  Form. — The  size  varies  from  very  small  growths 
to  enormous  tumors — one  case  weighing  forty-four  and  a  half  pounds. 
Spencer  enucleated  a  tumor  of  fourteen  pounds  from  the  broad  liga- 
ment nine  hours  before  delivery  at  term.  The  tumors  may  be  single, 


392 


PELVIC  NEOPLASMS 


or  multiple.  They  are  rarely  noted  as  bilateral  growths.  Thierry,  in 
1906,  reported  a  bilateral  growth.  Eising  reported  another  in  1911 
which,  together  with  the  uterus,  constituted  a  mass  measuring 
7^x4/4*3  M  inches. 

Most  of  the  fibroids  of  the  broad  ligaments  are  sessile  tumors,  but 
Vance  collected  9  cases  which  were  pedunculated.  Nearly  all  of  these 
are  supposed  to  have  developed  from  the  ovarian  ligament,  yet  there 
is  always  a  possibility  that  some  arose  from  the  fibrous  tissue  in  the 
depth  of  the  broad  ligament  and  are  identical  frcm  the  standpoint 
of  origin  with  tumors  which  project  through  the  obturator  foramen 
and  sacrosciatic  notch  which  have  been  discussed  under  fibroids  of 
the  vulva  (page  i).  Vance's  case  was  a  vascular  growth  of  twelve 
and  a  half  pounds  which  had  no  connection  with  the  normal  uterus. 
Bevers,  in  1909,  reported  two  pedunculated  growths  which  developed 
from  the  ovarian  ligament  and  had  undergone  torsion. 

The  outline  of  the  tumors  is  identical  with  that  of  fibroids  in  other 
parts  of  the  body.  Their  surfaces  are  irregularly  rounded,  depending 
upon  their  position. 

Growth.— As  a  rule,  the  tumors  grow  slowly,  since  they  are  usually 
of  fibrous  tissue.  Soft  myomatous  tumors  grow  faster.  The  growths 
have  been  known  to  be  present  from  one  to  twenty  years  before 
removal. 

Degenerations. — The  same  degenerations  observed  in  uterine 
fibroids  may  occur  with  fibroids  of  the  broad  ligament. 

Cystic  degeneration  is  a  rather  common  occurrence.  As  a  rule, 
the  cysts  do  not  attain  great  size,  yet  McNeile's  case  in  1909  contained 
ten  quarts  of  clear  straw-colored  fluid. 

Hyaline  degeneration  has  been  frequently  described.  Two  cases  of 
Vance's  series  presented  extensive  areas  of  calcification. 

Adenomyoma. — Some  of  the  cystic  tumors  which  have  been  de- 
scribed as  cystic  fibroids  are  undoubtedly  adenomyomata  which  may 
develop  as  primary  processes  according' to  von  Recklinghausen's  theory 
of  origin  from  wolffian  remnants  or  as  secondary  processes  from  the 
rectovaginal  septum,  cervix,  uterus,  tube  or  round  ligament.  They 
have  been  described  under  their  proper  heading. 

Symptoms. — The  symptoms  of  fibromyoma  of  the  broad  ligament 
are  variable,  but  essentially  they  are  like  those  of  uterine  fibroids.  Pain 
is  the  result  of  pressure  or  of  adhesions.  When  the  uterus  is  normal, 
there  need  be  no  disturbance  of  menstruation.  Symptoms,  as  a  rule, 
develop  gradually  and  may  be  present  for  many  years.  McNeile's 
case  has  given  symptoms  for  more  than  ten  years.  In  an  unreported 
case  seen  by  one  of  us,  symptoms  had  been  present  for  five  years 
before  they  were  sufficient  to  force  the  patient  to  seek  relief  with  a 
tumor  the  size  of  a 'fetal  head.  The  slow  growth  of  the  tumor  is  a 
distinguishing  feature. 


TUMORS   OF   THE   BROAD   LIGAMENT  393 

Lipoma. — Lipoma  of  the  broad  ligament  is  rare.  Lockyer,  in  1919, 
was  able  to  collect  only  7  cases.  In  2  of  these  reported  by  Borrmann 
the  round  ligament  dwindled  away  as  it  passed  over  the  fatty  tumor, 
suggesting  that  the  neoplasm  might  be  associated  with  an  arrest  in 
development  of  the  round  ligament.  Lockyer  reported  a  case  asso- 
ciated with  an  ovarian  dermoid  cyst.  It  lay  in  the  base  of  the  meso- 
salpinx,  was  encapsulated  and  severed  from  the  cyst  wall.  Emrys- 
Roberts  described  a  case  in  which  the  tumors  were  situated  in  the 
broad  ligaments  immediately  below  the  posterior  part  of  the  fimbriated 
ends  of  the  fallopian  tubes.  They  were  discovered  accidentally  during 
the  pathological  examination  of  a  specimen  of  ovarian  fibroid  com- 
plicating uterine  fibroids. 

The  size  varies  tremendously.  Emrys-Roberts'  case  presented  as 
two  bean-sized  nodules.  One  of  Borrmann's  measured  7.5x6.5x4  cen- 
timeters. It  was  bilobed.  Bland  Sutton  and  Giles  cite  one  which 
reached  as  high  as  the  navel  and  weighed  5  kilograms.  One  of  the 
tumors  described  by  Emrys-Roberts  contained  two  small  clear  cysts 
lined  by  columnar  epithelium  which  the  observer  believed  indicated  an 
origin  from  Kobelt's  tubules. 

The  tumors  are  encapsulated,  nonadherent,  and  therefore  are 
easily  removed. 

Sarcoma. — Webster  states  that  primary  sarcoma  of  the  broad  liga- 
ment is  extremely  rare  and  is  usually  discovered  only  when  the  con- 
dition is  inoperable.  According  to  Bland  Sutton,  it  is  usually  of  the 
spindle-cell  type  and  rapidly  growing.  There  is  no  doubt  but  that 
a  considerable  proportion  of  cases  in  the  literature  adduced  as  primary 
sarcoma  may  equally  well  be  regarded  as  secondary  extensions  from 
a  process  primary  in  the  ovary,  since  many  of  the  cases  are  so  late 
when  seen  that  the  anatomic  relations  cannot  always  be  precisely 
determined.  There  is  no  doubt,  however,  but  that  the  tumor  can 
develop  from  aberrant  ovarian  tissue  situated  in  the  broad  ligament. 
Such  a  case  was  described  by  Outerbridge,  in  1919,  in  which  there  was 
a  cystic  sarcoma  the  size  of  an  adult  head  in  the  broad  ligament  of  a 
girl  of  nineteen.  The  ovary  was  not  involved,  although  the  tumor 
was  adherent  to  the  intestine.  Cystic  degeneration  was  present. 
Microscopically  the  tumor  exhibited  the  typical  picture  of  a  spindle- 
celled  sarcoma  of  a  somewhat  fibrosarcomatous  type  containing  areas 
suggesting  the  structure  of  ovarian  stroma.  -Davies,  in  1914,  reported 
a  case  in  which  the  landmarks  were  more  definite.  The  tumor  was 
walnut  size,  situated  in  the  base  of  the  broad  ligament  of  the  right 
side  at  the  level  of  the  cervix.  It  bulged  into  the  vagina  and  caused 
pain.  It  proved  to  be  a  typical  spindle-celled  sarcoma.  The  uterus 
and  adnexa  were  normal.  The  tumor  recurred  four  months  after 
removal  and  five  months  later  reached  almost  to  the  umbilicus. 


394  PELVIC  NEOPLASMS 

Dermoids. — Dermoids  of  the  broad  ligament  are  rarely  seen.  They 
originate  in  the  subserous  cellular  tissue  and  present  the  same  char- 
acteristics observed  in  ovarian  dermoids.  A  few  cases  have  been  seen 
in  pelves  presenting  normal  ovaries.  There  are  several  theories  ad- 
vanced to  explain  their  origin.  The  majority  believe  that  they  develop 
from  aberrant  ovarian  tissue  which  has  been  included  within  the  folds 
of  the  broad  ligament.  Others  hold  that  they  arise  from  an  impreg- 
nated egg  from  which  one  of  the  original  cell  elements  has  been 
extruded  and  exists  as  a  fetal  inclusion  as  a  fetus  within  a  fetus  (blas- 
tomere).  Others  see  the  growth  as  an  expression  of  misplaced  germ 
cells  which  develop  parthenogenetically.  A  few  consider  that  they 
represent  defective  twin  development. 

Since  the  tumors  usually  develop  in  the  depth  of  the  broad  liga- 
ment, they  tend  to  grow  downward,  pushing  the  pelvic  structures  to 
one  side.  Cases  have  been  described  in  which  they  have  been  extruded 
from  the  ischiac  fossa  to  appear  under  the  skin  of  the  buttocks.  Freund 
states  that  they  may  vary  in  size  from  a  pigeon's  egg  to  that  of  a  fetal 
head. 

Their  shape  is  more  or  less  oval,  depending  somewhat  upon  the 
pressure  which  is  exerted  upon  them,  since  they  are  more  or  less 
flaccid  in  structure.  The  histologic  picture  is  similar  to  that  of  der- 
moids of  the  ovary.  The  fluid  contents  of  the  tumor  may  be  non- 
distinctive  or  contain  the  characteristic  sebaceous  or  atheromatous 
material  with  or  without  hair  or  teeth. 

Broad  ligament  dermoids  grow  very  slowly  and  their  symptoms 
depend  almost  entirely  upon  pressure  disturbances.  Occasionally,  they 
become  infected. 

Treatment  of  Solid  Tumors  of  the  Broad  Ligament. — Since  the 
exact  nature  of  the  growth  cannot  be  determined  before  operation,  the 
tumor  should  be  removed  as  soon  as  its  presence  is  known,  because 
of  the  chance  of  malignant  degeneration.  This  rule  holds  true  even 
in  the  absence  of  symptoms.  Often  the  neoplasm  can  be  shelled  out 
of  the  broad  ligament  leaving  the  other  structures  intact.  The  larger 
growths  may  be  removed  only  after  hysterectomy  because  of  the 
vascular  field. 

TUMORS  OF  THE  FALLOPIAN  TUBES 

Tumors  of  the  tubes'  may  develop  from  embryonic  elements  in- 
cluded in  that  structure  or  from  secondary  degeneration  of  its  adult 
tissues.  For  the  purpose  of  study,  we  will  divide  them  according  as 
they  arise  from  epithelium  or  mesoblastic  tissues.  Teratoma  and 
dermoid  are  considered  under  the  head  of  embryoma.  The  tumors 
may  be  cystic  or  solid.  The  cystic  swellings  on  the  surface  of  the  tube 
result,  as  a  rule,  from  inflammatory  conditions.  Under  the  head  of 


TUMORS    OF   THE    BROAD    LIGAMENT  395 

solid  tumors  are  included  nearly  all  true  neoplasms  of  the  tube.  They 
may  be  benign  or  malignant. 

Benign  Tumors  of  the  Tubal  Epithelium. — This  group  is  composed 
of  polyps  and  papilloma. 

POLYPS. — There  is  considerable  controversy  as  to  whether  the  cases 
reported  as  polyps  are  true  neoplasms  analogous  to  similar  formations  in 
the  cervix  and  body  of  the  uterus.  The  6  cases  which  have  been  reported 
(Beck,  Breslau,  Leopold,  two  cases;  Wyder,  and  Huffmann)  have  all  been 
associated  with  pregnancy  and  were  recorded  in  the  older  literature.  All 
of  them  exhibited  decidual  changes  and  most  of  them  were  thought  to 
have  caused  the  arrest  of  the  ovum  and  to  have  been  responsible  for  the 
rupture  of  the  tube  in  the  ectopic  pregnancy.  They  had  not  presented 
symptoms. 

PAPILLOMA. — The  papilloma  are  villus  or  cauliflower  growths  which 
arise  from  the  endosalpinx.  They  were  first  described  by  Doran,  in  1879, 
as  "exuberant  morbid  growths  which  lie  in  the  interior  of  the  fallopian 
tube."  Doran  regarded  them  as  of  inflammatory  origin. 

They  are  very  rare  tumors.  Lockyer,  in  his  critical  review,  accepted 
but  1 6  cases. 

Etiology. — The  majority  of  investigators  who  have  reported  cases 
support  Doran's  view  that  the  condition  is  a  papilloma  which  has  developed 
upon  an  inflammatory  basis.  While  there  is  some  exception  to  this  theory, 
it  is  a  fact  that  in  nearly  all  of  reported  cases,  there  had  been  preceding 
salpingitis. 

The  ages  of  patients  presenting  this  condition  ranged  from  thirty-nine 
to  fifty  years  in  the  series  collected  by  Sanger  and  Barth. 

Appearance  and  Form. — The  size  of  the  tumor  varies.  It  may  range 
between  that  of  an  orange  and  that  of  a  small  melon.  The  tube  is  not  only 
distended  by  the  tumor  but  by  a  considerable  amount  of  fluid.  Sometimes 
the  latter  is  so  great  as  to  constitute  a  hydrosalpinx.  The  growth  may 
form  a  rounded  or  elliptical  swelling  in  the  outer  portion  of  the  tube. 
Between  it  and  the  uterus,  the  tube  may  appear  unaltered.  The  tube  is 
usually  enveloped  in  firm  adhesions.  The  mass  may  lie  in  the  true  pelvis 
or  in  the  lower  abdomen. 

The  tumor  may  present  as  villus  and  papillary  types  (Macrez).  In 
the  former,  the  growth  exhibits  long  cylindrical  or  conical  processes.  The 
papillary  form  is  a  more  advanced  stage  of  the  villus  type  and  results 
from  proliferation  of  the  slender  villi.  Ulceration  and  necrosis  are  not 
present  in  the  benign  papilloma.  This  distinguishes  them  from  the  malig- 
nant papilloma  of  the  tube. 

The  fimbriated  portion  of  the  tube  may  be  closed,  in  which  case  the 
tube  assumes  the  form  of  a  cyst.  On  the  other  hand,  both  the  uterine 
and  fimbriated  end  may  be  closed  or  the  fimbriated  end  may  be  the  only 
patent  extremity.  The  fluid  contained  in  the  tube  has  been  studied  by 
Macrez,  Doran  and  others,  and  is  found  to  vary  from  a  thick,  mucous 


3g6  PELVIC  NEOPLASMS 

or  syrupy  fluid  to  a  thin,  pale,  serous  material.  Macrez  emphasizes  that 
an  admixture  of  blood  is  a  sign  of  malignancy. 

On  microscopical  examination,  the  tumor  is  composed  of  papillae 
which  arise  independently  from  the  wall  of  the  tube.  The  excrescences 
are  invested  by  a  single  layer  of  columnar  epithelium  which  may  or  may 
not  show  cilia.  The  folds  of  the  tube  are  obliterated  and  are  replaced 
by  the  outgrowths.  The  mass  is  vascular.  At  the  base  of  the  papillae,  the 
stroma  cells  are  usually  but  not  invariably  crowded  together.  Their  nuclei 
stain  deeply.  Hyaline  and  occasionally  mucoid  degenerations  are  present 
in  the  apex  of  the  mass.  There  are  no  signs  suggestive  of  malignancy. 

Symptoms. — These  are  not  constant.  They  depend  often  upon  the 
patency  of  the  tube,  its  location  and  the  presence  of  adhesions.  When 
the  uterine  end  of  the  tube  is  patent,  and  the  fimbriated  end  is  closed,  fluid 
escapes  through  the  uterus  into  the  vagina.  The  discharge  is  intermittent 
and  results  only  when  a  certain  fluid  pressure  has  been  reached  in  the  tube. 
The  discharge  is  accompanied  by  pain  and  temporary  disappearance  of  the 
swelling.  When  the  uterine  end  of  the  tube  is  closed,  but  the  fimbriated 
portion  is  open,  the  fluid  may  escape  into  the  peritoneum  and  irritate  it 
so  as  to  cause  ascites.  A  large  tubal  cyst  may  form  when  both  ends  of  the 
tube  are  closed. 

The  ascites  is  not  an  essential  feature  of  the  growth.  It  may  not  be 
regarded  as  evidence  of  malignancy,  since  the  fluid  from  the  tube  excites 
the  peritoneum  to  considerable  secretion.  It  is  believed  that  a  small  amount 
of  fluid  forced  from  the  tube  into  the  peritoneal  cavity  is  the  cause  of  an 
irritative  peritonitis  resulting  in  dense  adhesions. 

Treatment. — Because  malignant  papilloma  are  far  more  common  than 
the  benign  growths  in  the  tube,  the  removal  should  be  radical  and  include 
the  uterus,  and  both  adnexa. 

Prognosis. — The  prognosis  is  good. 

Carcinoma  of  the  Tube. — Carcinoma  of  the  tube  may  be  primary 
or  secondary.  Both  forms  are  extremely  rare.  The  first  case  of 
primary  carcinoma  of  the  fallopian  tube  was  described  by  Orthmann 
in  1888.  Other  cases  were  soon  reported,  so  that  Peham,  in  1903, 
was  able  to  collect  63  cases  in  the  literature.  Since  then,  there  have 
been  various  tabulations  every  few  years.  In  1914,  Vest  collected  132 
cases.  Lockyer,  in  1917,  found  4  other  cases  in  the  literature. 

The  rarity  of  the  disease  is  emphasized  by  all  students  of  the 
question.  Norris  states  that  carcinoma  of  the  tube  is  a  hundred  times 
as  rare  as  carcinoma  of  the  uterus.  Vest  states  that  there  were  only 
4  cases  of  tubal  carcinoma  in  19,000  patients  treated  in  Kelly's  clinic 
in  Baltimore.  Hurden  reports  that  there  had  been  but  3  cases  of 
primary  tubal  carcinoma  received  in  the  gynecological  laboratory  of 
the  Johns  Hopkins  Hospital  as  against  400  uterine  carcinoma.  Norris, 
in  his  report  which  included  the  material  from  the  University  Hospital 
of  Pennsylvania  found  only  I  case  of  primary  carcinoma  of  the  tube 


TUMORS   OF   THE   BROAD   LIGAMENT 


397 


in  2,020  gyneologic  specimens.  In  the  material  were  assembled  8 
secondary  carcinoma  of  the  tube,  5  of  which  were  from  growths  which 
were  primary  in  the  ovary  and  3  primary  in  the  uterus. 

ETIOLOGY. — The  etiology,  as  in  carcinoma  in  general,  is  not  known. 
The  majority  of  students  of  the  question  have  contented  themselves  with 
a  search  for  predisposing  causes.  These  center  about  inflammation  and 
pregnancy. 

Tubal  carcinoma  arising  in  tuberculous  tubes  have  been  described  by 
von  Franque,  in  1911,  Lipschitz,  in  1914,  and  Lady  Barrett,  in  1916. 
Lipschitz  has  collected  26  cases  seen  in  association  with  salpingo-oophoritis. 
Sanger  and  Barth  and  others  have  urged  sterility  and  single  pregnancies 
as  indicative  of  previous  inflammation.  Doran  believes,  however,  that  the 
carcinoma  may  develop  independently.  Vest  states  that  43  per  cent  of  his 
collected  cases  gave  no  history  of  a  previous  pelvic  inflammation.  On  the 
contrary,  it  is  well  known  that  tubal  inflammation  may  result  without  defi- 
nite clinical  symptoms.  The  question  of  preexisting  salpingitis  must  be 
settled  by  the  microscope.  While  not  absolutely  conclusive,  there  is  much 
reason  to  believe  that  cancer  of  the  tube,  as  cancer  in  general,  is  not  likely 
to  develop  in  absolutely  normal  tissues. 

Many  have  urged  that  pregnancy  and  resulting  puerperal  morbidity  are 
predisposing  causes,  yet  the  evidence  does  not  appear  convincing.  Vest 
stated  that  70  per  cent  of  his  series  had  been  pregnant.  Of  the  79  parous 
women,  28  per  cent  had  borne  one  child  only.  Lockyer  sanely  calls  attention 
to  the  fact  that  such  data,  without  controls,  or  the  percentage  of  the  total 
female  population  that  have  become  pregnant,  cannot  be  studied  critically. 

AGE. — The  age  of  the  patient  has  ranged  between  twenty-seven  and 
seventy.  Fifty-three  per  cent  of  Vest's  series  occurred  between  the  ages 
of  forty  and  fifty,  at  a  time  when  malignancy  is  most  likely  to  develop  in 
other  parts  of  the  body.  The  data  concerning  the  age  is  presented  in  the 
following  table: 


CASES 

Age 

Doran 

Vest 

27-30 

3 

30-35 

3 

35-40 

4 

ii 

40-45 

8 

30 

45-50 

30 

38 

50-55 

18 

19 

55-6o 

18 

60-65 

4 

65-70 

i 

CLASSIFICATION. — The  disease  may  present  as  papillary  carcinoma  or 
papillary  alveolar   (adenocarcinoma). 


398  PELVIC  NEOPLASMS 

PAPILLARY  CARCINOMA  OR  MALIGNANT  PAPILLOMA. — It  is  difficult  to 
determine  the  relative  frequency  of  the  various  types  of  growths,  since 
definite  data  is  often  lacking  as  to  reported  cases.  In  Vest's  table,  29  cases 
were  described  sufficiently  accurately  to  allow  classification.  Twelve  of 
these  were  malignant  papilloma.  Lockyer  feels  3  others  should  be  added. 
The  majority  believe  that  papillary  carcinoma  are  more  common  than 
adenocarcinoma  and  arise  from  conversion  of  benign  forms.  Histologi- 
cally,  a  malignant  papilloma  shows  invasion  of  the  tubal  wall  by  prolifer- 
ating epithelium.  The  epithelial  investment  of  the  papillae  also  shows 
marked  proliferation  and  metaplasia.  Areas  of  necrosis  and  cystic  spaces 
are  common. 

ADENOCARCINOMA. — This  type  is  more  uncommon.  Only  4  of  Vest's 
table  of  29  cases  were  definitely  classified  as  adenocarcinoma.  Lockyer  adds 
3  others.  The  tumor  presents  a  smooth,  yellowish  or  whitish  gray  cut 
surface.  The  consistency  varies,  since  the  tumor  mass  may  be  soft  or  quite 
dense.  The  epithelial  masses  may  be  distinguished  from  the  fibrous  stroma 
on  careful  inspection.  Under  the  microscope,  one  obtains  the  characteristic 
appearance  of  adenocarcinoma.  Areas  of  round  cell  infiltration  are  fre- 
quently found  on  the  advancing  edges. 

EXTENSION  AND  METASTASES. — Veit  states  that  pure  papillary  carci- 
noma is  long  confined  to  the  interior  of  the  tube  and  does  not  invade  the 
wall  until  late  in  the  disease.  This  type  frequently  spreads  to  the  ovary. 
On  the  other  hand,  the  adenocarcinoma  early  penetrate  the  wall  and  occa- 
sionally may  rupture  the  serosa,  through  which  they  spread  to  the  perito- 
neum and  omentum.  The  retroperitoneal  lymph  glands  may  be  involved 
through  the  lymphatics.  This  occurred  in  7  of  43  of  Stolz's  cases.  Peri- 
toneal metastases  have  been  described  by  Novy,  Kehrer,  and  others.  Cullen 
has  recorded  metastases  to  the  stomach  and  rectum.  The  liver  (Tonyos), 
the  bladder  (Doran),  the  skin  (Baisch),  supraclavicular  lymph  glands 
(Rossinsky),  vagina  (Spencer),  and  the  diaphragm  (Vest)  have  been  the 
seat  of  metastases.  The  uterine  mucosa  may  be  involved  by  secondary 
implantations,  as  may  the  uterine  wall  by  lymphatic  drainage.  Implantation 
metastases  following  operation  have  been  reported  by  von  Rosthorn  and 
Osterloh. 

SYMPTOMS  AND  SIGNS. — Unfortunately,  there  are  no  characteristic 
symptoms  of  tubal  carcinoma.  Vest  states  that  the  fact  that  this  neoplasm 
appears  so  frequently  at  the  time  of  the  menopause  tends  to  mask  the  true 
nature  of  the  disease.  The  usual  symptoms  are  the  following:  (i)  a 
watery  vaginal  discharge;  (2)  abdominal  pain;  (3)  alteration  of  menstru- 
ation; (4)  ascites;  (5)  cachexia;  (6)  tumor. 

Discharge. — A  watery  discharge  presented  in  27  per  cent  of  cases  col- 
lected by  Doran.  It  may  be  continuous  or  appear  in  gushes.  Usually 
watery  and  yellow  at  first,  it  later  becomes  bloodstained  and  even  hemor- 
rhagic.  The  periodic  discharge  is  often  accompanied  by  abdominal  pain. 
The  presence  of  a  sanguineous  discharge  and  tubal  swelling  is  highly  sug- 


TUMORS   OF   THE   BROAD   LIGAMENT  399 

gestive  of  malignant  disease  of  the  tube.  Quite  naturally,  a  discharge  may 
occur  only  when  the  uterine  end  of  the* tube  is  patent. 

Abdominal  Pain. — Pain  was  present  in  53  per  cent  of  the  cases  re- 
ported by  Doran.  It  may  be  generalized  throughout  the  abdomen  or 
limited  to  the  pelvis.  It  frequently  radiates  to  the  back  and  down  the  sides. 
The  pain  may  be  colicky,  such  as  occurs  with  acute  torsion  of  an  ovarian 
tumor,  or  may  be  constant§and  dull,  with  a  feeling  of  discomfort  and  weight 
in  the  pelvis.  There  may  be  a  close  connection  between  the  pain  and  the 
vaginal  discharge.  Severe  attacks  of  pain  in  women  with  chronic  sal- 
pingitis  should  suggest  the  possibility  of  tubal  carcinoma. 

Menstrual  Disturbances. — Dysmenorrhea  is  not  as  common  as  menor- 
rhagia  or  metrorrhagia.  Vaginal  bleeding  may  occur  in  women  who  have 
passed  the  menopause.  Yet  menstrual  disturbances  may  be  indefinite  and 
vague,  and  of  little  value  as  far  as  statistical  purposes  are  concerned. 

Ascites. — Ascites  is  common  in  late  growths.  It  is  generally  ascribed 
to  reactions  of  secondary  deposits  in  the  peritoneum,  since  the  ostium 
through  which  irritating  fluids  could  escape  was  open  in  only  I  per  cent  of 
cases.  Occasionally,  it  is  present  in  large  amounts.  Two  gallons  were 
removed  at  operation  in  Le  Count's  case. 

Cachexia. — Cachexia  is  usually  a  late  symptom  as  is  common  in  all 
malignant  disease.  It  may  be  out  of  proportion  to  the  symptoms  which 
have  been  present. 

Tumor. — Tumors  of  considerable  size  may  cause  enlargement  of  the 
abdomen.  They  are  accompanied  by  ascites.  They  are  usually  quite  fixed 
and  may  give  symptoms  of  incomplete  intestinal  obstruction.  Often,  how- 
ever, there  is  no  abdominal  swelling.  Even  by  bimanual  vaginal  examina- 
tion, nothing  more  than  an  indistinct  resistance  may  be  met  in  the  vaginal 
fornices.  This  may  be  further  masked  by  the  presence  of  ascites. 

DIAGNOSIS. — There  are  no  characteristic  symptoms  or  signs  of  tubal 
carcinoma.  The  condition  may  be  suspected  when  there  is  a  tumor  in  the 
lateral  pelvis  in  a  case  presenting  a  history  of  a  previous  tubal  inflamma- 
tion, a  sanguineous  watery  discharge,  especially  if  it  is  intermittent  and 
accompanied  by  abdominal  pain.  A  soft,  rounded  swelling  in  one  or  other 
of  the  broad  ligaments  and  the  presence  of  ascites  will  make  the  diagnosis 
more  likely,  but  it  may  be  difficult  to  exclude  an  ovarian  or  tubo-ovarian 
cyst.  The  former  was  noted  n  times  in  Doran's  series  of  cases  as  an 
accompaniment  to  the  cancer.  Tubo-ovarian  cysts  were  found  as  a  com- 
plication in  26  cases  tabulated  by  Lipschitz.  When  the  tumor  is  firm,  it 
may  be  readily  confused  with  a  fibroid.  The  latter  was  observed  in  asso- 
ciation with  carcinoma  of  the  tube  9  times  in  Doran's  series  of  cases. 
Occasionally,  there  may  be  neither  signs  nor  symptoms  of  the  growth 
which  may  be  so  small  that  its  true  character  can  be  revealed  only  with 
the  microscope. 

TREATMENT. — The  treatment  is  panhysterectomy  and  the  removal  ol 
both  adnexa.  If  a  tube  is  removed  supposedly  for  hydrosalpinx  and  found 


400  PELVIC  NEOPLASMS 

to  be  cancer,  the  other  tube  and  ovary  and  the  uterus  should  be  removed 
immediately.  The  primary  mortality  in  Doran's  collected  cases  was  6  per 
cent. 

PROGNOSIS. — The  prognosis  is  not  good.  Only  4  cases  survived  the 
five-year  period  of  cure  in  the  cases  that  were  followed  in  the  complete 
series  collected  by  Vest.  The  majority  of  recurrences  develop  in  the  first 
year.  Doran  checked  the  post-operative  results  in  40  cases,  10  of  which 
were  dead  or  dying  within  six  months  to  a  year  after  operation.  Giles 
found  10  recurrences  soon  after  21  operations.  Stoltz  states  that  alveolar 
growths  recurred  sooner  than  the  papillary  forms. 

Secondary  Carcinoma  of  the  Tube. — The  tube  may  be  involved 
secondary  to  uterine  or  ovarian  cancer.  Kundrat's  figures  show  the 
relative  frequency  of  the  involvement  of  the  tube  in  carcinoma  primary 
in  the  uterine  body  and  cervix.  The  tube  was  involved  3  times  in 
24  fundal  carcinoma  and  not  at  all  in  80  cases  of  cervical  cancer. 
Taussig,  in  1907,  recorded  a  carcinoma  of  the  tube  and  ovary  secondary 
to  a  cervical  cancer.  The  tube  is  invaded  usually  early  in  ovarian 
cancer  and  late  in  uterine  carcinoma.  The  organ  may  be  invaded  by 
implantation  upon  the  serous  or  mucous  coats  or  by  the  lymph  stream 
to  the  wall  of  the  tube.  The  tube  may  be  invaded  during  the  general 
peritoneal  spread  of  cancer  from  the  upper  abdomen. 

Benign  Tumors  of  Mesoblastic  Origin. — ENCHONDROMA. — Small 
cartilaginous  tumors  occasionally  have  been  described  as  arising  from  the 
tubes.  Many  consider  them  allied  to  the  embryoma.  They  tend  to  project 
into  the  lumen  and  occlude  it.  Outerbridge  felt  that  his  tumor  was  a  causal 
factor  in  a  tubal  pregnancy. 

LIPOMA. — Only  2  cases  of  lipoma  are  described  in  the  literature. 
Parona's  case  was  reported  in  1901.  It  weighed  three  ounces  and  appeared 
to  surround  and  infiltrate  the  tube.  Doran  described  a  small,  fatty  tumor 
in  the  ovarian  fimbria  hanging  by  a  distinct  pedicle. 

LYMPHANGIOMA. — Leighton,  in  1912,  collected  4  cases  and  reported 
one  other.  They  are  all  small,  about  the  size  of  a  large  pea.  On  microscopic 
examination,  the  tumor  is  composed  of  loose  connective  tissue  filled  with 
cavities  or  crypts,  lined  by  a  single  layer  of  epithelial  cells.  All  the  cases 
occurred  with  uterine  fibroids. 

FIBROMYOMA. — These  are  rare  tumors.  Auvray,  in  1912,  exhaustively 
studied  29  cases.  Rudolph,  in  1898,  reported  one  pure  fibroma.  Fibro- 
myoma  may  arise  from  any  part  of  the  tube.  Occasionally  they  project 
from  the  ovarian  fimbria.  They  are  almost  always  unilateral  and  usually 
single.  Ordinarily  small,  they  may  attain  considerable  size.  Auvray's  case 
weighed  2,800  grams. 

Tubal  fibroids  may  be  subperitoneal,  interstitial,  or  submucous.  The 
former  is  the  most  common. 

Neither  the  size  nor  symptoms  are  characteristic.  They  are  usually 
mistaken  for  uterine  fibroids.  Their  treatment  is  removal. 


TUMORS   OF   THE   BROAD   LIGAMENT  401 

ADENOMYOMA. — There  is  considerable  discussion  as  to  whether  there 
is  such  a  primary  condition.  The  majority  of  cases  reported  as  such  are 
now  considered  salpingitis  isthmica  nodose. 

Malignant  Tumors  of  Mesoblastic  Origin. — SARCOMA. — Sarcoma  of 
the  tube  is  a  very  unusual  condition.  There  are  only  8  cases  reported  as 
primary  tumors,  the  cases  of  Gottschalk,  Janvrin,  Jacobs  (2  cases),  Jones 
(3  cases),  and  Scheffzek.  Quenu  and  Longuet,  and  Doran  have  reviewed 
the  literature. 

MIXED  TUMORS. — These  consist  of  embryonic  connective  tissue  and 
cylindrical  epithelium.  Six  cases  have  been  reported  as  carcinosarcoma. 

PERITHELIOMA. — Perithelioma  are  extremely  rare  tumors.  Cosset's 
case  weighed  one  and  a  half  pounds.  Miiller  describes  a  case  in  which  there 
were  tumors  of  both  tubes. 

Embryonal  Tumors. — DERMOID  CYSTS  AND  TERATOMA. — These  occur 
extremely  rarely.  Lockyer  describes  a  teratoma  and  collects  6  others.  They 
range  in  size  from  small  nutlike  masses  to  tumors  the  size  of  a  fetal  head. 


LITERATURE 

AUVRAY.    Arch.  mens.  d'obst.  et  de  gynec.     1912.     i:  i. 

BLAND  SUTTON  AND  GILES.    Diseases  of  Women.     1906. 

BROWN.    Am.  J.  Obst.     1919.    79:  561. 

CULLEN.    Archives  Surgery.     1920.     1:215. 

DAVIES.     Proc.  Roy.  Soc.  Med.,  London.     1914.     15:8. 

DORAN.    Allbutt,  Playfair,  Eden  Syst.  Gynec.     1906. 

DURAND.     Gynec.  et  Obst.     1920.     2:123. 

EISING.     Med.  Rec.     1911.     79:  532. 

EMANUEL.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1902.    47:138. 

EMRYS-ROBERTS.    Lancet.    1909.    2:  186. 

HUFFMAN.    J.  Am.  M.  Ass.    1915.    65:1360. 

IRAETA.    Internat.  Abstract  Surg.     1917.    25:  560. 

JACOBS.     Progres   med.  beige.     1905. 

JONES.    Am.  J.  Obst.     1893.    2&:  324. 

KEHRER.     Monatschr.  f.  Geburtsh.  u.  Gynak.     1908.     27:  327. 

KRUSEN.    Am.  J.  Obst.     1908.     57:  666. 

LEOPOLD.    Sitzung  der  Gesellschaft  fur  Geburtshilfe.    Leipzig,  1876. 

LEWIS.    Am.  J.  Obst.    1908.    48:  1003. 

LOCKYER.     Proc.  Roy.  Soc.  Med.     1919.     12:  195. 

MACREZ.     Des  tumeurs  papillaires  de  la  trompe  de  fallope,  these,  Paris 

1899. 

MCNEILL.     Am.  J.  Obst.     1919.     79:  657. 
MEYER,  R.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1900.    43:  88. 
NORRIS.     Surg.,  Gynec.  &  Obst.     1909.     8:272. 
NOVY.    Monatsschr.  f.  Geburtsh.  u.  Gynak.     1900.     11:1043. 


402  PELVIC  NEOPLASMS 

ORTHMANN.    Ztschr.  f.  Geburtsh.  u.  Gynak.     1906.    58:  376. 

OUTERBRIDGE.      Am.  J.  Obst.       1914.      24:408. 

QUENU  ET  LONGUET.    Rec.  de  chir.     1901.    24:  408. 

SAENGER  AND  EARTH.    Martin,  Krankh.  d.  Eileiter.    Leipz.,  1895.    P-  345- 

VANCE.    Ann.  Surg.     1907.    46:  854. 

VEST.    Johns  Hopkins  Hosp.  Bull.     1914.    25:305. 

WALTHER.     Journal  Revue  mens.  de  gynecologic  d'obstetrique  et  de  pedi- 

atrie.     1919.     14:60. 
WEBSTER.    Dis.  Women.     1907. 


CHAPTER  XIV 

MAMMOTH  OVARIAN  TUMORS 

Historical — Frequency — Complications  of — Types  of  fluid — Symptomatology — Age — Prog- 
nosis— Resume  of  cases. 

Historical. — The  subject  of  mammoth  tumors  forms  a  chapter  of 
peculiar  interest  in  ovarian  pathology.  In  view  of  the  natural  human 
curiosity  concerning  things  unusual,  it  is  rather  remarkable  that  no  one 
has  yet  made  a  collection  of  these  cases  which  even  approaches  com- 
pleteness. 

Gould  and  Pyle,  in  their  extensive  compilation  of  unusual  cases  in 
medicine  published  in  1897,  mention  only  7  cases  in  which  the  weight 
of  the  tumor  exceeded  100  pounds.  The  largest  of  these  weighed  182 
pounds  (Reifsnyder's  case).  Bullitt,  in  1900,  collected  25  cases  over 
100  pounds,  and  later  authors  have  added  isolated  cases  to  this  review. 
Brunner,  Idazewski,  and  Zacharias  each  include  a  bibliography  with  their 
reports  going  more  extensively  into  the  foreign  literature.  Fay,  in 
1908,  reporting  a  tumor  which  weighed  about  175  pounds,  without  at- 
tempting to  make  his  bibliography  exhaustive,  was  able  to  find  reports 
of  38  cases  over  100  pounds;  of  these,  14  weighed  between  150  and 
200  pounds,  and  5  over  200  pounds. 

A  more  careful  review  of  the  literature  gives  us  records  of  87  cases 
weighing  over  100  pounds,  and  in  addition  there  were  found  records 
of  103  cases  where  the  weight  was  between  60  and  100  pounds.  Of  the 
80  cases,  there  were  21  between  150  and  200  pounds,  9  between  200 
and  300  pounds,  and  I  over  300. 

The  geographical  distribution  of  these  cases  is  of  some  interest. 
Thirty-seven  were  reported  from  the  United  States,  5  from  South 
America,  7  from  England,  n  from  Germany,  10  from  France,  3  each 
from  Belgium  and  India,  2  each  from  Switzerland  and  China,  I  each 
from  Italy,  Austria  and  Holland.  The  Russian  literature,  much  of  the 
Dutch  and  parts  of  the  Chinese  and  Indian  were  not  available.  Very 
possibly  these  contain  some  cases  large  enough  to  include  in  our 
review,  yet  it  is  impossible  to  judge  this  from  the  titles  of  articles,  as  even 
a  5o-pound  tumor  would  seem  enormous  to  one  who  had  never  seen 
one  which  was  larger. 

Spencer  Wells'  first  series  of  1,000  ovariotomies  contained  only  I 
tumor  which  weighed  over  100  pounds.  This  weighed  125  pounds, 

403 


404  PELVIC  NEOPLASMS 

but  this  patient  came  from  the  Argentine  to  be  operated  upon  by  Wells. 
The  other  large  cases  in  this  series  weighed  81,  78,  77,  75,  72  and  63 
pounds  respectively;  all  the  others  were  below  60  pounds.  The  aver- 
age weight  in  Wells'  first  series  of  500  cases  was  20.3  pounds. 

In  spite  of  the  fact  that  most  tumors  are  operated  upon  nowadays 
long  before  they  attain  any  such  enormous  size,  we  find  that  27  or 
nearly  one-third  of.  the  total  number  of  cases  in  this  series  have  been 
reported  since  1900.  It  may  be  that  the  greater  rarity  of  large  tumors 
prompts  us  to  record  a  larger  proportion  of  such  growths.  Yet  Spohn's 
328-pound  case,  reported  from  Texas  in  1905,  would  have  been  re- 
markable enough  to  record  in  any  age,  as  would  Tuffier's  94-liter  case 
published  in  1906,  or  Pfaehler's  97  kilogram  growth  in  1904.  Peaslee 
in  his  monograph  on  "Ovarian  Tumors"  in  1872  states  that  "the  largest 
amount  of  fluid  in  an  ovarian  tumor  which  has  been  recorded  is  160 
pounds,  which  was  drawn  off  during  an  operation  of  ovariotomy  by 
Kimball,  more  than  20  pounds  being  still  left  because  he  could  not 
complete  the  operation."  He  was  evidently  unfamiliar  with  the  2 
very  much  larger  cases  in  European  literature  which  are  mentioned 
in  Gallez's  work  of  1873,  namely,  Martineau's  2i6-pound  case  and 
Adelmann's  214-pound  case.  Emmett,  in  1879,  stated  that  "Dr.  Keith 
had  removed  a  tumor  weighing  120  pounds,  the  largest  ovarian  tumor 
ever  removed  successfully  from  the  living  body."  Nor,  as  we  might 
suppose,  do  all  the  present-day  cases  come  from  remote  districts. 
Ward's  222-pound  case  was  a  resident  of  San  Francisco.  Smith's 
192-pound  case  had  received  the  benefits  of  electricity  and  "Christian 
Science"  in  Boston  for  two  years  prior  to  her  operation.  Franz's 
i6o-pound  case,  operated  in  1916,  had  lived  for  years  almost  in  the 
shadow  of  one  of  the  larger  Berlin  hospitals. 

Two  methods  of  arriving  at  the  weights  of  these  larger  tumors  are 
commonly  used,  yet  both  are  subject  to  certain  inaccuracies.  The  first 
adds  the  weight  of  fluid  removed  to  that  of  the  sac ;  and,  when  accu- 
rately controlled,  this  method  is  entirely  reliable.  But  fluid  is  fre- 
quently lost  at  the  time  of  operation  and  the  exact  amount  is  difficult 
to  determine.  In  other  cases,  as  in  those  of  Spohn  and  Barlowe,  the 
patients  were  tapped  one  or  more  times  for  a  number  of  days  before 
final  removal  of  the  tumor.  In  such  cases,  the  amount  of  fluid  due  to 
re-accumulation  is  of  course  unknown.  Yet  Peaslee,  speaking  from 
cases  which  were  treated  only  by  repeated  tappings,  considers  two 
pounds  a  day  a  very  rapid  rate  of  re-accumulation,  and  possibly  this 
factor  is  of  minor  importance.  In  many  of  the  older  case  reports, 
where  the  tumors  were  merely  tapped,  the  weight  of  the  fluid  only 
could  be  obtained;  in  these  we  must  either  accept  the  author's  estimate 
of  the  weight  of  the  sac  or  exclude  the  case  from  the  series.  The 
weight  of  the  sac  may  be  considerable — up  to  50  pounds. 

The   other   method   commonly   used   subtracts   the   weight   of   the 


MAMMOTH   OVARIAN   TUMORS  405 

patient  after  operation  from  her  weight  previous  to  it.  It  is,  however, 
rarely  possible  to  weigh  a  patient  immediately  after  operation.  At  a 
later  time,  her  loss  in  weight  from  edema  or  her  gain  in  weight  from 
improved  nutrition  are  factors  that  must  be  considered,  though  for- 
tunately they  usually  counterbalance  each  other.  Ascitic  fluid  occurs 
so  rarely  that  ordinarily  it  need  not  be  considered.  Twenty-five 
pounds,  however,  would  probably  be  a  very  liberal  estimate  of  the 
error  by  any  of  these  methods  of  determination.  This  becomes  a  com- 
paratively small  factor  when  we  consider  the  enormous  weight  of  the 
larger  tumors. 

Due  to  the  variation  in  shape  of  the  abdomen,  the  circumference 
in  these  cases  varies.  It  is  usually  greater  than  the  height  of  the 
patient;  in  all  the  larger  tumors  it  was  considerably  over  six  feet.  The 
graphic  description  given  by  Spohn  may  convey  a  better  idea  of  the 
size  than  any  measurements.  "The  tumor  came  almost  up  to  her  chin 
and  extended  midway  between  her  knees  and  feet.  When  she  lay  on 
her  side  on  a  three-quarter  bed,  it  had  to  be  supported  on  two  chairs. 
She  could  not  reach  her  navel  with  her  hands  by  one  and  a  half  feet, 
and  was  so  emaciated  that  without  her  tumor  companion  she  would 
hardly  make  a  shadow."  The  volume  of  fluid  contained  in  Spohn's 
cyst  was  thirty-six  gallons,  Bullitt's  contained  thirty-four  gallons.  The 
average  bathtub  has  a  capacity  of  fifty-seven  gallons. 

The  weight  of  the  sac  varies  from  2.5  to  70  pounds,  the  larger  sacs 
usually  belonging  to  the  multicystic  type  of  tumor  with  its  numerous 
subsidiary  cysts. 

The  weight  of  the  patient  before  operation  in  several  of  the  larger 
cases  was  nearly  400  pounds.  In  Binkley's  case  it  was  396  pounds,  in 
Bullitt's  "near  400,"  in  Smith's  375  pounds.  Spohn  does  not  state  the 
weight  of  his  patient.  Due  to  the  patient's  usual  condition  of  emacia- 
tion, her  weight  after  operation  is  frequently  far  less  than  that  of  the 
tumor.  The  most  marked  contrast  is  presented  in  Payot's  seventeen-year- 
old  girl  who  weighed  66  pounds  after  the  removal  of  a  igS-pound  tumor. 

Complications. — The  enormous  abdominal  distention  and  the  pres- 
sure effects  of  the  great  tumor  mass  gives  rise  to  very  characteristic 
deformities.  The  ribs  are  usually  widely  flaring,  the  xyphoid  fre- 
quently standing  almost  at  right  angles  to  the  body.  The  ilia  ffare 
widely.  In  Henley's  case,  the  erectores  spinae  were  greatly  hyper- 
trophied  to  support  the  enormous  weight,  forming  two  ropelike  strands 
at  either  side  of  the  vertebral  column.  Edema  of  the  legs  is  present 
in  almost  all  cases,  edema  of  the  lower  part  of  the  abdominal  wall  in 
very  many.  The  skin  of  the  abdominal  wall  is  either  hypertrophied 
and  thickened  by  edema,  or  so  distended  that  it  is  very  thin  and  tense. 
The  abdominal  veins  are  usually  very  markedly  distended,  often  being 
as  much  as  i  centimeter  in  diameter.  Pressure  ulcers  are  common, 
both  on  the  legs  and  on  the  abdominal  wall.  Pressure  atrophy  of  the 


406  PELVIC   NEOPLASMS 

thigh  muscles,  where  the  tumor  is  in  contact  with  them,  is  very  fre- 
quent and  with  the  massive  edema  below  gives  rise  to  a  very  peculiar 
picture,  just  after  the  tumor  is  removed. 

The  thoracic  organs  are  always  displaced  upwards.  The  heart's 
apex  impulse  was  frequently  found  in  the  third  space.  The  liver  and 
spleen  were  sometimes  flattened.  The  ovary  involved  by  the  tumor 
was  the  right  in  17  cases,  the  left  in  13,  both  in  3,  and  not  stated  in  52. 
The  condition  of  the  other  pelvic  organs  is  not  stated  in  many  cases, 
as  many  of  the  reports  are  incomplete.  The  uterus  showed  complete 
prolapse  in  only  2  cases.  Baldwin's  i85-pound  case  was  the  mother 
of  two  children,  Sauligoux's  loo-pound  case  was  an  unmarried  girl 
of  fifteen.  In  the  series  of  103  cases  between  60  and  100  pounds,  complete 
prolapse  occurred  6  times,  2  times  in  nulliparas,  and  partial  prolapse  2 
times,  once  in  a  nullipara.  The  uterus  was  infantile  in  a  number  of 
cases.  In  the  cases  past  the  menopause  it  showed  senile  atrophy.  Co- 
incident myomata  of  the  uterus  were  noted  in  3  cases.  Buffett's 
i8o-pound  unilocular  cyst  of  the  left  ovary  had  also  a  subperitoneal 
fibroid  weighing  36  pounds. 

In  42  cases,  the  type  of  ovarian  pathology  is  not  stated.  In  35  cases, 
the  cysts  were  multilocular,  probably  of  the  pseudomucinous  type. 
In  6  cases,  they  were  unilocular.  There  was  I  dermoid  weighing  100 
pounds.  In  this  case,  the  other  ovary  also  contained  a  dermoid.  There 
was  i  parovarian  cyst  of  the  left  broad  ligament  weighing  105  pounds. 
There  were  2  papillary  cysts.  One  weighed  154  pounds.  The  patient 
recovered  from  the  immediate  results  of  the  operation  but  died  three 
months  later  of  generalized  abdominal  metastases.  The  other  weighed 
125  pounds.  This  patient  was  discharged  well  on  the  twenty-sixth 
day  following  her  operation,  but  her  later  history  is  not  stated. 

Type  of  Fluid. — The  type  of  fluid  was  usually  gelatinous  in  the 
multicystic  tumors.  As  is  usual  in  pseudomucinous  cysts,  the  color 
and  consistency  frequently  varied  markedly  in  the  different  chambers, 
from  a  light  greenish  to  a  dark  chocolate  or  even  black.  The  mono- 
cysts  usually  contained  thin,  clear  fluid. 

Adhesions  are  of  much  importance  in  the  operative  technic,  and 
rendered  many  of  the  operations  extremely  difficult.  In  37  cases,  the 
presence  or  absence  of  adhesions  is  not  mentioned.  In  3,  it  is  defi- 
nitely stated  that  there  were  no  adhesions.  Twenty-six  cases  had 
parietal  adhesions,  including  adhesions  to  the  diaphragm.  In  5  cases 
the  location  of  adhesions  is  not  mentioned.  Four  had  visceral,  12 
had  both  visceral  and  parietal.  The  visceral  adhesions  included  both 
large  and  small  intestine,  omentum,  stomach,  liver,  gall-bladder,  uterus 
and  urinary  bladder. 

Symptomatology. — The  symptomatology  of  these  cases  is  that  due 
to  pressure  and  the  mechanical  inconvenience  because  of  the  size  of 
the  tumor.  Many  had  no  complaint  except  the  latter.  Many  even 


MAMMOTH  OVARIAN  TUMORS  407 

of  the  larger  cases  had  been  able  to  get  about  or  even  to  perform 
their  housework,  until  a  few  months  before  the  time  they  came  under 
observation.  In  the  later  stages,  however,  their  condition  was  most 
deplorable.  They  became  bedridden  and  entirely  helpless,  or  possibly 
able  to  get  about  only  on  all  fours.  Most  of  them,  because  of  dyspnea, 
were  unable  to  lie  flat;  some  had  to  sit  up  in  a  chair  continually. 
Emaciation  is  constantly  present,  many  have  nausea  and  vomiting. 
Palpitation  is  a  frequent  symptom.  Constipation  is  present  in  many 
cases.  Oliguria  and  dysuria  are  frequent.  Pain  is  a  rare  complaint. 
A  number  of  cases  had  pain  early  while  the  tumor  was  yet  small, 
although  it  disappeared  later  when  the  tumor  reached  large  dimen- 
sions. The  duration  of  symptoms  is  difficult  to  obtain.  The  symptoms 
are  usually  so  vague  and  develop  so  gradually  that  the  patient  cannot 
state  definitely  when  they  began.  The  duration  of  the  tumor  is  men- 
tioned in  47  cases.  It  varied  from  ten  months  to  twenty-one  years. 

Age. — In  31  cases,  the  age  of  the  patient  is  not  stated.  There 
were  3  cases  between  ten  and  twenty  years,  12  between  twenty  and 
thirty,  6  between  thirty  and  forty,  15  between  forty  and  fifty,  15 
between  fifty  and  sixty,  3  between  sixty  and  seventy,  2  between  seventy 
and  eighty — a  remarkably  high  proportion  in  women  past  the  period 
of  active  sexual  life. 

The  number  of  pregnancies  is  mentioned  in  38  cases.  Five  were 
single,  10  were  married  but  sterile,  6  had  had  one  child,  n  several, 
6  had  had  many;  of  these  2  had  had  fifteen  children.  The  menstrual 
history  is  given  in  only  33  instances,  whether  because  such  a  large 
proportion  of  tumors  occur  after  the  menopause  i^hard  to  state.  One 
patient  of  fifteen  years  had  never  menstruated.  A  patient  of  seven- 
teen had  had  three  of  four  periods  when  fourteen  years  of  age  and 
none  later.  Eleven  state  that  the  tumor  developed  some  years  after 
the  menopause.  Five  had  had  amenorrhea  of  three  months  to  two 
years'  duration  before  the  time  of  the  menopause.  One  had  a  very 
short  interval  between  periods.  In  4  the  menses  were  undisturbed. 

Prognosis. — The  prognosis  in  these  large  tumors,  whether  without 
or  with  operation,  is  extremely  serious.  The  outcome  was  not  stated 
in  24  cases  of  this  series,  mostly  early  cases  before  the  days  of  opera- 
tions. Three  were  operated.  Presumably  all  died,  since  there  is  no 
note  to  the  contrary.  In  12  cases,  a  fatal  outcome  without  operation 
is  recorded.  Fifteen  cases  died  following  operation,  9  within  a  few 
hours,  5  later,  in  i  the  time  of  death  is  not  stated.  Shock  is  given 
as  the  cause  of  death  in  the  earlier  cases.  Hemorrhage  is  not  men- 
tioned in  any  case  as  a  cause  of  death,  but  the  results  of  post-mortem 
examinations  are  not  recorded.  The  cause  of  death  in  2  cases  which 
died  on  the  second  day  is  also  given  as  shock;  I  on  the  sixth  day  as 
"exhaustion";  i  on  the  seventh  day  as  intestinal  obstruction,  I  on  the 
thirty-seventh  day  as  sepsis.  In  this  latter  case,  marsupialization  was 


4o8  PELVIC  NEOPLASMS 

done,  the  only  case  in  this  series  where  this  procedure  was  applied. 
Immediate  recovery  was  recorded  in  36  cases,  of  these  one  died  one 
month  after  operation,  of  pneumonia,  apparently  without  relation  to 
the  operation.  One  died  in  three  months  from  metastases  following 
the  removal  of  a  papillary  cyst.  One  died  in  six  years  of  pulmonary 
cancer,  but  the  type  of  ovarian  pathology  in  this  case  is  not  recorded. 

The  percentage  of  recovery  of  all  cases  in  the  series  was  41.4  per 
cent;  of  the  operated  cases,  71  per  cent;  of  the  cases  over  175  pounds, 
30  per  cent  recovered,  of  those  operated  55  per  cent.  The  prognosis 
in  women  with  the  larger  tumors  was  much  worse  than  the  smaller. 
Though  the  death  rate  of  operative  cases  since  1900  has  not  decreased 
notably,  73  per  cent  recovering,  the  total  recovery  rate  is  much  higher, 
59  per  cent,  since  a  larger  proportion  of  cases  were  operated. 

Although  the  outcome  in  cases  not  operated  is  usually  death 
within  a  comparatively  few  years,  it  is  remarkable  how  long  such  a 
patient  may  occasionally  live  in  comparative  comfort  with  frequent 
tappings.  The  case  of  Martineau  long  stood  as  a  classic.  The  dried 
cyst  wall  is  preserved  in  the  Museum  of  the  Royal  College  of  Surgeons. 
"The  patient  was  twenty-seven  years  old  when  the  disease  commenced 
after  a  miscarriage  with  her  first  child.  Between  the  years  of  1757 
and  August,  1783,  when  she  died,  she  w7as  tapped  eighty  times,  and 
in  these  operations  there  were  altogether  removed  from  her  6,631 
pints  of  fluid  or  upwards  of  thirteen  hogsheads.  One  hundred  and 
eight  pints  was  the  largest  quantity  ever  taken  away  at  one  time. 
She  was  never  tapped  more  than  five  times  in  one  year,  and  the  largest 
quantity  in  one  year  was  four  hundred  and  ninety-five  pints." 

A  far  more  remarkable  case,  however,  is  reported  in  recent  years 
by  Ashby.  This  patient  first  applied  for  treatment  to  Dr.  J.  L.  Atlee, 
of  Pennsylvania,  in  November,  1861.  He  removed  thirty-two  pints  of 
fluid,  and  each  year  thereafter  until  1885  the  same  quantity  was  re- 
moved. In  1880  Dr.  Atlee  urged  ovariotomy,  but  after  examination 
concluded  it  was  too  dangerous  and  resumed  simple  evacuation.  Be- 
ginning March,  1885,  it  was  necessary  to  tap  more  frequently,  five 
times;  in  1886,  nine  times;  in  1887,  eleven  times;  in  1888,  sixteen  times; 
from  then  until  1896,  eighty-eight  times,  and  then  every  three  or  four 
weeks.  By  1903  her  vitality  was  so  lowered  that  an  ovariotomy  was 
advised  as  the  only  means  of  saving  life.  The  patient  had  been  tapped 
two  hundred  and  sixty-nine  times  in  forty-two  years  and  two  thousand 
one  hundred  and  twelve  gallons,  or  nearly  seventeen  thousand  pints, 
or  more  than  thirty-three  hogsheads  of  fluid  had  been  withdrawn. 
Operation  was  performed  on  November  n,  1903.  An  area  of  abdomi- 
nal wall  4  by  6  inches  was  excised,  the  point  of  entrance  for  the 
numerous  trocar  wounds.  The  wall  here  was  two  and  a  half  inches 
thick.  Pedicle  attaching  the  tumor  to  the  uterus  was  very  small,  the 
sac  was  easily  detached  after  the  abdominal  walls  had  been  cut  away. 
The  tumor  had  obtained  nourishment  through  its  attachment  to  the 


MAMMOTH  OVARIAN  TUMORS  409 

wall.  The  patient  also  had  general  miliary  tuberculosis  of  the  peri- 
toneum. Her  recovery  was  uneventful.  One  year  later  her  left 
breast  was  removed  because  of  a  tumor.  She  had  gained  twenty 
pounds,  and  was  in  excellent  health. 

Vance's  case  was  tapped  one  hundred  and  eighty-four  times  in 
forty-six  years,  and  finally  died  of  exhaustion  aged  eighty,  after  twenty- 
two  thousand  pounds  of  fluid  had  been  removed  from  her.  Other  less 
remarkable  cases  in  which  from  five  hundred  to  six  thousand  pounds 
of  fluid  were  removed  by  repeated  tappings  over  three  to  ten  years 
are  reported  by  Griffin,  Shands,  Falckner,  Mead,  Gilliam,  Brown, 
Pagenstecher,  Souligoux,  Lee,  Helmuth  and  Neal. 

The  post-operative  condition  in  the  cases  which  recovered  is  of 
some  interest.  Pain  in  the  ribs  is  a  frequent  complaint  due  to  the 
sudden  relief  of  tension.  There  is  frequently  a  diuresis  beginning  at 
the  third  or  fourth  day,  with  a  disappearance  of  the  edema. 

There  is  a  peculiar  deformity  due  to  the  marked  flaring  of  the 
ribs.  In  one  case  it  was  stated  that,  immediately  after  the  operation, 
one  could  reach  up  through  the  lax  abdominal  wall  and  touch  the 
under  surface  of  the  third  rib.  It  is  remarkable  how  soon  after  oper- 
ation the  deformity  disappeared.  One  case  was  practically  normal 
in  four  weeks.  Difficulty  in  walking,  and  in  maintaining  balance  is 
often  mentioned  in  the  early  convalescence. 

Due  probably  to  the  poor  condition  of  the  patients,  a  plastic  oper- 
ation to  strengthen  the  abdominal  wall  was  not  attempted  in  any  case 
with  a  tumor  over  100  pounds,  though  it  is  mentioned  in  several  cases 
weighing  between  60  and  100  pounds.  It  was  occasionally  a  difficult 
matter  to  dispose  of  the  folds  of  skin  to  prevent  maceration.  Usually 
this  was  accomplished  by  the  interposition  of  folds  of  cotton  or  gauze. 
Visceroptosis  is  not  mentioned  in  any  of  the  reports  which  state  the 
later  condition  of  the  patient  (13  cases).  Several  state  definitely  that 
the  abdominal  wall  was  firm;  sometimes  with  considerable  fat.  A 
number  of  the  patients  were  doing  hard  work  within  six  months  or  a 
year  later. 

Resume  of  Cases. — The  accompanying  table  gives  the  cases  weigh- 
ing over  100  pounds.  Short  resumes  of  the  cases  over  200  pounds 
should  be  of  interest. 

Spohn's  case — 328  pounds,  reported  from  Texas  in  1905.  Mrs.  G., 
age  forty-three  years,  children  seven.  Duration  of  disease,  several  years, 
numerous  tappings;  30  gallons  of  gelatinous  fluid  removed  with  small 
trocar  during  week  immediately  preceding  operation;  only  six  gallons 
present  at  time  of  operation.  Multicystic  tumor  left  ovary.  Sac 
weighed  40  pounds.  Recovery. 

Barlowe — 298  pounds,  reported  from  Kentucky,  1846.  Patient  bed- 
ridden for  long  time,  semireclining  with  shoulders  much  elevated 
because  of  dyspnea.  From  acetabulum  across  umbilicus,  6  feet,  6 
inches.  During  three  days,  19.5  gallons,  which  equals  176  pounds  of 


4io  PELVIC  NEOPLASMS 

fluid  removed.  Patient  died  of  exhaustion  next  day.  At  autopsy,  72 
pounds  of  fluid  and  50  pounds  of  wall  removed,  consisting  of  cysts  size 
of  lemon  to  child's  head.  Tumor  originated  in  left  ovary — nowhere 
adherent. 

Bullitt — 245  pounds,  Kentucky,  1897.  Patient  age  thirty-seven 
years,  children,  one.  Tumor  present  many  years.  Operation  arranged 
eight  years  previously  but  courage  failed.  Last  one  and  a  half  years 
could  rest  only  sitting.  Dyspnea  and  weakness.  Circumference  of 
abdomen  at  navel,  79  inches.  Twenty-four  gallons  of  fluid  removed 
at  operation.  Extensive  parietal  and  visceral  adhesions.  Multilocular 
cyst.  Died  of  intestinal  obstruction  seventh  day. 

Tuffier — 235  pounds,  France,  1906.  Patient  age  seventy  years,  chil- 
dren, one,  age  forty-seven  years.  No  history  of  pelvic  trouble. 
Menopause  at  forty.  Tumor  for  six  years.  Gradual  general  enlarge- 
ment of  abdomen  without  change  of  health  or  inconvenience.  Bed- 
ridden for  one  year  with  dyspnea  and  palpitation.  Cyst  drained  94 
liters  fluid  first  operation,  removed  three  weeks  later.  Uneventful 
recovery  with  later  complete  restoration  abdominal  wall  and  thorax  to 
normal. 

Binkley — 225  pounds,  Chicago,  1897.  Fluid  in  tumor  weighed  175 
pounds,  solid  portion  50  pounds.  Weight  of  patient  before  operation, 
396  pounds.  Case  terminated  fatally  because  of  too  rapid  delivery  of 
fluid.  Tumor  very  heavy,  thick-walled  with  numerous  adhesions,  sep- 
arated with  great  difficulty. 

Ward — 222  pounds,  California,  1907.  Patient  age  forty-seven 
years,  children  3.  Tumor  present  seventeen  years,  catamenia  regular 
until  forty-five.  Weight  before  operation,  309.5,  24  gallons  fluid.  Cir- 
cumference umbilicus,  6  feet  10  inches.  Multilocular  cyst  right  ovary 
with  firm  and  dense  adhesions  to  liver,  gall-bladder,  spleen,  intestiftes 
and  peritoneum.  Death  due  to  shock  one  hour  post-operative. 

Martineau — 216  pounds,  England,  1784.  Case  cited  without  details 
by  Gallez. 

Adelmann — 214  pounds,  Germany.  Case  cited  without  details  by 
Gallez. 

Pfaehler — 202  pounds,  Switzerland.  Patient  age  forty-two  years ; 
tumor  five  years;  able  to  do  housework  until  one  year  previous.  For 
several  months  could  only  lie  on  bed  or  kneel.  Emaciation,  dyspnea, 
palpitation,  edema  legs  and  labia,  constipation.  Circumference  abdo- 
men 170  centimeters.  Operation,  74  liters  fluid  removed — cyst  four 
chambers  left  ovary — adherent  to  parietal  peritoneum  and  diaphragm. 
Weight  tumor  97  kilograms,  of  patient  47  kilograms.  Recovery. 

Garcelon — 202  pounds,  American.  Patient  age  twenty-eight  years, 
normal  weight  115  pounds,  circumference  at  umbilicus,  69  inches. 
Both  ovaries  diseased.  Fluid  132  pounds,  sac  70  pounds.  Patient  never 
rallied,  died  two  days  post-operative. 


MAMMOTH  OVARIAN  TUMORS 
MAMMOTH  OVARIAN  TUMORS 


411 


Weight  re- 
ported (Ibs.) 

Author 

Locality 

Date  dis- 
covered 

Age 

Outcome 

328 

Spohn 

Texas 

1905 

43 

Recovery 

298 

Barlowe 

Kentucky 

1846 

? 

Death  without  operation 

245 

Bullitt 

Kentucky 

1897 

37 

Death    seven    days    after 

operation 

235(?) 

Tuffier 

France 

1906 

70 

Recovery 

225 

Binkley 

Illinois 

1896 

? 

Death  at  operation 

222 

Ward 

California 

1907 

47 

Death  one  hour  after  oper- 

ation 

216 

Martineau 

England 

1784 

? 

Not  stated  —  without  oper- 

ation^) 

214 

Adelmann 

Germany 

1816 

? 

Not  stated  —  without  oper- 

ation(?) 

202 

Pfaehler 

Switzerland 

1904 

42 

Recovery 

2O2 

Garcelon 

America 

1882 

28 

Death  two  days  after  oper- 

ation 

198 

Dayot 

France 

1893 

17 

Recovery 

192 

Smith 

Massachusetts 

1906 

42 

Death  twenty-four  hours 

post  -operative 

185 

Baldwin 

England 

1900 

59 

Death  without  operation 

182.5 

Reifsnyder 

China 

1895 

25 

Recovery 

1  80 

Buffett 

Rouen 

1887 

? 

Death  without  operation 

i6o  +  (2o)? 

Kimball 

Massachusetts 

1872 

? 

Operation  not  completed 

176  + 

Gallo 

Argentine 

1919 

? 

?  —  probably   death   with- 

out operation 

176 

Gilliam 

New  York 

1899 

45 

Operated  —  result    not 

stated 

175  + 

Fay 

Tennessee 

1908 

54 

Death    one    month    after 

operation 

I75(?) 

Mudd 

St.  Louis 

1884 

? 

Not  operated 

166 

Spohn 

Texas 

? 

? 

Death  at  operation 

165 

Maritan 

Marseilles 

1893 

? 

Recovery 

164 

Harley 

India 

1921 

40 

Death  next  day  after  op- 

eration 

1  60 

Cordier 

Missouri 

1905 

? 

Death  few  hours  after  op- 

eration 

1  60 

Gaitskell 

England 

1873 

? 

? 

1  60 

Davis 

Pennsylvania 

1893 

55 

Death  six  hours  after  op- 

eration 

1  60 

Franz 

Germany 

1916 

So 

Recovery 

154 

Cullingsworth 

England 

1891 

45 

Death  at  operation 

i54(?) 

B  runner 

Germany 

1901 

44 

Death  three  months  after 

operation  —  metastases 

152 

Squire 

Massachusetts 

1870 

65 

Death  without  operation 

15° 

Tozetti 

Italy 

1897 

? 

? 

149 

Briddon 

New  York 

1890 

36 

Death  twelve  hours  after 

operation 

148  + 

Peaslee 

Massachusetts 

1860 

21 

? 

U7 

Phoehler    (quoted 

by  Pelliza) 

? 

? 

? 

146 

Rodenstein 

America 

1878 

45 

Death  without  operation 

140 

Larkins 

India 

1912 

62 

Death  without  operation 

140 

Peaslee 

America 

1872 

? 

? 

140  + 

Aquino 

India 

1895 

40 

Death  without  operation 

140 

Gallez 

France 

1873 

? 

?  —  probably   death   with- 

out operation 

139^        Edmonds 

China 

1915 

? 

Recovery 

412 


PELVIC   NEOPLASMS 
MAMMOTH  OVARIAN  TUMORS — Continued 


Weight  re- 
ported (Ibs.) 

Author 

Locality 

Date  dis- 
covered 

Age 

Outcome 

134 

Idazewski 

Germany 

1903 

63 

Death  thirty-seven  days 

132 

Poncet 

France 

1889 

57 

? 

132 

McGillicuddy 

America 

1825 

28 

? 

130 

Caballero 

Argentine 

1914 

22 

? 

129  + 

Mann 

Holland 

1888 

? 

Recovery 

128 

Unterberger 

Germany 

1898 

p 

Recovery 

128 

Wenzel 

Vienna 

1908 

58 

Recovery 

«5(?) 

Lynds 

Michigan 

1898 

54 

Recovery 

«5(?) 

Atlee 

America 

1871 

33 

Death  three  hours 

125 

Estes 

Pennsylvania 

1887 

40 

Recovery 

125 

Wells 

England 

1873 

53 

Recovery 

(Brazil) 

121 

Caballero 

Argentine 

1906 

52 

Recovery 

I20(?) 

Ponchon 

Brussels 

1881 

58 

Recovery 

1  2O 

Keith 

Scotland 

1879 

? 

Recovery 

I  2O 

Martineau 

England 

1784 

? 

?  —  death   without   opera- 

tion 

II9 

Neal 

Kentucky 

1880 

33 

Death  without  operation 

II9 

Yondell      (quoted 

? 

? 

? 

Cartledge) 

116 

Horsley 

America 

1911 

33 

Recovery 

116 

Kelly 

Maryland 

1885 

42 

Recovery 

116 

Brown 

England 

1849 

3i 

Death  without  operation 

114 

Falckner 

Switzerland 

1893 

53 

Recovery 

112 

St.  Toth 

Germany 

1902 

58 

Recovery 

112 

Samson 

England 

1815 

? 

?  —  death    without    opera- 

tion 

112 

Gallez 

France 

1873 

? 

?  —  death   without   opera- 

tion 

112 

Goodell 

Pennsylvania 

1882 

3i 

Recovery 

III 

Cartledge 

Kentucky 

1891 

30 

Recovery 

III 

Keen 

Pennsylvania 

1893 

15 

Recovery 

III 

Knight 

Pennsylvania 

1912 

? 

Recovery 

no 

Rouffart 

Belgium 

1900 

59 

Recovery 

IIO(?) 

West 

England 

1851 

24 

Death 

no 

Potvin 

Belgium 

1900 

59 

Recovery 

1  06 

Gibb 

London 

1855 

3i 

Death  without  operation 

106  + 

Peaslee 

America 

1860 

? 

?  —  probably    death    with- 

. 

out  operation 

105 

Mayo-Robson 

England 

1884 

37 

Recovery 

i°5 

Homans 

Massachusetts 

1884 

? 

Recovery 

104 

Skutsch 

Germany 

1904 

53 

Recovery 

IO2  + 

Bosch 

Germany 

1873 

? 

?  —  death    without    opera- 

tion 

IO2 

Van  den  Bosch 

America 

1883 

? 

?  —  death    without    opera- 

tion 

IOO 

Burford 

England 

1892 

55 

Recovery 

100 

Fussell 

Pennsylvania 

1901 

47 

Death     few    hours    after 

operation 

IOO 

Keith 

England 

1895 

55 

Good  recovery 

IOO 

Kelly 

Maryland 

1886 

? 

? 

80+20 

Peaslee 

America 

1849 

28 

Death  without  operation 

IOO? 

Worner 

Germany 

1899 

65 

Death  without  operation 

IOO  + 

Worner 

Germany 

1899 

76 

Recovery 

IOO 

Willi 

Germany 

1873 

? 

?  —  death    without   opera- 

tion 

INDEX 


Abbe's  work  with  radium  in  uterine  can- 
cer, 264 

Abdominal   exploration,   139 
Abdominal   hysterectomy,    for  fibroids,    136 
Abdominal  incision,  closure  of,   142 
Abdominal  metastases,  204 
Abdominal  myomectomy,  closure  of  cavity, 
130 

—  illustrated,  127 

—  shelling  out  tumor,  129 

—  technic,   126 

Abdominal    operations,    for   fibroids,    open- 
ing abdomen,  138 

—  preparation  of  patient,  138 
Abnormal    pregnancy    and    chorio-epitheli- 

oma,  306 
Abortion,  caused  by  fibroids,  158 

—  hydatidiform  degeneration  of  chorion  in, 

307 

Acardiacus  in  dermoid  cyst,  361 
Acetone  treatment  of  cancer,  249 
Actinium,  radio-active,  262 
Action  of  radium,  264 
Adenocarcinoma,  of   Bartholin's  glands,  33 

—  of  cervix,  193 

—  of   clitoris,   32 

—  of  fallopian  tube,  398 

—  of  fundus  with  fibroids,  118 

—  of  uterus,  193-196 

—  of  uterus,  and  fibroids,  probable  common 

origin,  283,  284 

—  primary,  of  uterine  body,  279 

—  pseudomucinosum,  347 
Adenofibromata  of  ovary,  340 
Adenofibromyxochondrosarcoma,  295 
Adenoma,  hydradenoid,  13 

—  ovarian,  solid,  336 
Adenomyoma,  and  pelvic  peritonitis,  169 

—  bibliography,  174,  175 

—  cervical,    168 

—  degeneration  of,   168 

—  of  broad  ligament,  392 

—  of  ovary,  376 

—  of  para-ovarian,  390 

—  of  rectovaginal  septum,  172,  173 

—  of  rectovaginal  septum,  symptoms,  173 

—  of  tube,  401 

—  other  than  uterine,  172-174 

—  submucous,    168 

—  subperitoneal  and  intraligamentous,  167 
• —  tuberculous  complication  of,   169 


Adenomyoma,  uterine,  and  pelvic,  163-175 

—  Cullen's  classification,  165 

—  diagnosis,  170 

—  etiology,  163,  164 

—  —  frequency,   163 
histology,  167 

—  of  normal  contour,  165 

—  physical  findings,  169 

—  prognosis,  171 

—  symptoms,  169 

—  treatment,  172 
Adenomyositis,  173 

Adnexa  normal,  not  removed  in  hysterec- 
tomy, 142 

Adnexal  complications  with  fibroids,  97 
Adrenal  metastases,  204 
Adrenalin  in  fibroid  cases,  113 
Age   incidence,   of  broad  ligament  tumors, 
385 

—  of  cancer,   183 

—  in  carcinoma,   of   Bartholin's   glands,   34 

—  of  clitoris,  30 

—  of  fallopian  tube,  397 

—  of  uterine  body,  280 

—  in  chorio-epithelioma,  307 

—  of  dermoid  cysts,  358 

—  of  fibroma,  of  ovary,  369 

—  of  broad  ligament,  391 

—  of  fibromyoma,  of  uterus,  70 

—  of  vagina,  51 

—  of  mammoth  tumors,  407 

—  of  ovarian  carcinoma,  341 

—  of  sarcoma,  of  uterine  body,  290 
of  vagina,  in  adult,  63 

—  —  in  infancy,  59 
—  of  vulva,  37 

—  of  teratoma,  365 

—  vulvar  carcinoma,  21 
Age  influence  on  tumors,  3 
Aged  woman,  tumor  in,  3 
Alpha  rays  of  radium,  264 
Alveolar  sarcomata,  295 
Amenorrhea  in,  fibroid  cases,  119 

—  ovarian  tumor,  378 
Amputation  of  uterus,  141 

Amreich's    work    on    radiumization    of   the 

parametrium,  271 
Anemia,  danger  of,  in  fibroids,  in 

—  in  sarcoma  of  uterus,  298 
Anesthesia  for  hysterectomy,  138 
Angioma  of  ovary,  371 


413 


414 


INDEX 


Angiosarcoma,  295 

—  of  ovary,  374 

Appearance    and    form    of,    carcinoma    of 
Bartholin's  glands,  34 

—  of  clitoris,  30 

—  of  uterine  body,  281 

—  of  vagina,  56 

—  cysts  of  the  hymen,  17 

—  dermoid  cysts,  358 

—  fibroma,  of  broad  ligament,  391 

—  of  vulva,  3 

—  fibromyoma  of  vagina,  51 

—  lipoma  of  vulva,  n 

—  sarcoma  of  vagina,  in  adult,  64,  65 

—  in  infancy,  60 

—  sweat  gland  tumors  of  vulva,  15 

—  tubal  growths,  395 

—  vulvar  carcinoma,  22 

—  vulvar  sarcomata,  38 
Ascites  in,  cystic  ovary,  338 

—  endothelium  ovarii,  376 

—  fallopian  tube  tumors,  399 

—  ovarian  fibroids,  371 
Atheroma  and  uterine  fibroid,  99 
Atrophic  changes  in  uterine  fibroids,  82 
Auscultation  for  uterine  fibroids,  107 

Bartholin's  glands,  carcinoma  of,  32-35 

—  age  incidence,  34 

—  appearance,  34 

—  classification,  33 

—  etiology  of,  33 

—  frequency  of,  33 

—  tumors  of,  2 

Beclere's  statistics  of  fibroids,  119 
Benign  tumors  of,  outlet,  1-19 

—  uterus  and  cervix,  68-1 II 

—  vagina,  42-53 

—  vulva,  17,   1 8 

Beta  rays  of  radium,  264 
Bibliography  of,  adenomyoma,  174,  175 

—  benign  tumors  of  vagina,  53 

—  carcinoma  of  cervix,  214 

—  cervical  cancer,  278 

—  chorio-epithelioma,  322 

—  fibroids,  162 

—  of  uterus,  in 

—  ovarian  tumors,  382 

—  sarcoma,  of  uterus,  299 
of  vagina,  67 

of  vulva,  41 

—  tubal  tumors,  401 

—  tumors  of  vulva,  18 

Bicornate     uterus,     with     cervical     cancer, 

224 

Biphilloma,  361 

Bladder,  and  rectum,  protection  of,  in  radi- 
umization,  268 

—  disturbances  in  ovarian  tumor,  379 

—  effects  of  fibroids  on,  98 


Bladder,  involvement,  in  carcinoma  of  cer- 
vix, 198 
—  in  cervical  cancer,  206,  223 

—  separation  of,  in  supravaginal  hysterec- 

tomy,  140 

—  symptoms  in  uterine  fibroids,  104 
Blastomeres,  origin  of  embryoma,  357 
Bleeding,   atypical,   in   cervical   cancer,   206 

—  from  fibroids  during  pregnancy,  157 
Blondes,  possibly  more  affected  by  melan- 

otic  sarcoma,  37 

Blood,  and  lymph  supply  of  uterine  fibroids, 
80 

Blood,  cysts  of  ovary,  327 

Blood-stream  dissemination  of  sarcomatous 
metastases,  296 

Body  structures  represented  in  dermoid 
cysts,  360 

Border-line  carcinoma,  advantages  of  ra- 
dium, 274 

Border-line  cases,  resistant  to  radium,  275 

Border-line  of  operability  in  cervical  car- 
cinoma, 208 

Botryoids,  sarcomatous,  57,  60,  294 

Brain  metastases,  204,  313 

Breast,  changes  in  ovarian  tumor,  378 

—  metastases,  204 

Brettauer's  statistics  of  fibroids,  119 
Broad  ligament  tumors,  383-394 

—  adenomyoma,  392 

—  age  incidence,  385 

—  dermoid  cyst,  394 

—  diagnosis  of,  387 

—  etiology,  384 

—  fibromyoma,  391 

—  historical,  383 

—  lipoma,    393 

—  location  of  growth,  385 

—  microscopic  picture,  386 

—  prognosis  of,  387 

—  sarcoma,  393 

—  size  of  tumor,  385 

—  solid  types,  391 

—  symptoms  and  clinical  course,  386 

—  treatment  of  solid  tumors,  394 
Bromids,  use  of,  before  operation,  138 
Buckner's  case  of  mammoth  tumor,  6 
Bumm's  operation  in  cervical   cancer,  241, 

242 

Bumm's  statistics  on  cervical  cancer,  ra- 
diumization,  274 

Calcareous  degeneration  of  uterine  fibroids, 

83. 

Calcification  of  tumors,  10 
Calcified  fibroids,   death   from,  84 
Cancer,  acetone  treatment  of,  249 

—  and  heredity,  180 

—  and  meat-eating,  182 

—  and  nitrogen  balance,  180 


INDEX 


415 


Cancer,  and  sodium  chloride  excess,  180 

—  and  species,  180 

—  and  splenic  extract,  179 

—  and  vegetarianism,  182 

—  age  incidence  of,  183 

—  chronic  precancerous  conditions,  183 

—  class  influence  on,  181 

—  familial  incidence  of,  181 

—  five-year  period  of  cure,  254 

—  houses,   178 

—  immunity,   179 

—  in  young   child,    184 

—  infection,  178 

—  localities,  178 

—  lymphocytic  control  in,  179 

—  mortality,  254 

—  of  body  of  uterus,  279-299 

—  of  cervix,  cautery  methods,  245-247 

—  treatment,  216-277 

—  various  operations  for,  245-247 

—  of  ovary    differentiated  from  fibroid,  no 

—  of  rectum  differentiated  from  fibroid,  no 
Cancer,    of   uterus,    method   of    calculating 

results,  252-278 

—  organism,  and  ultramicroscopic  parasite, 

178 

—  philosophical  theories  of,  179 

—  racial  incidence,  182 

—  relation  to  fuel  used,  182 

—  statistics,  uniformity  of  method  needed, 

253 

—  treatment,  by  general  methods,  240 

—  drugs  formerly  in  vogue,  249 

—  See  also  Carcinoma 
Cancroid  carcinoma  of  vulva,  23 
Carcinoma,  and  sarcoma,  of  uterine  body, 

279-299 

—  Cohnheim's  theory,  177 

—  from  adenomyomatous  tissue,  168 

—  from  dermoid  cyst,  361-363 

—  of  Bartholin  glands,  32-35 

—  age  incidence,  34 
— •  appearance  of,  34 

—  classification,  33 

—  diagnosis  and  prognosis,  35 

—  etiology  of,  33 

—  frequency  of,  33 

—  of  cervical  canal,  squamous  cell,  191 

—  of  cervix,   196-203 

—  bibliography,  214 

—  bladder  involvement,  198 
-differentiation,  211 

-• early  stages,  207 

history  of  treatment,  216-219 

irritating  discharge,  2IO 

—  lymphatic  involvement,  109 

—  lymphosarcomatous  types,  295 
method  of  extension,  196 

prognosis,  213 

rectal  and  vesical  involvement,  199 


Carcinoma,  of  cervix,  second  stage,  208 

—  suggestive  symptoms,  209 

—  symptoms,  205,  206 

—  third  stage,  inoperable,  208 

—  treatment,  216-277 

—  of  clitoris,  28-32 

—  age  incidence,  30 

—  appearance,  30 

—  etiology,  29 

—  histology,  32 

—  metastases,  32 

—  parity  in,  30 

—  symptoms,  32 

—  of  fallopian  tube,  396,  397 

—  of  ovary,  340-381 

—  age  incidence,  341 

—  atypical  forms,  348 

—  classification,  341,  342 

—  clear  cell  cancer,  348 

—  clinical   features,  352-355 
complications  of,  355 

—  cystic  type,  345 

—  diagnosis,  355 

—  etiology,  340,  341 

—  folliculoma  malignum,  347 

—  frequency,  340 

—  involvement  of  lymph  glands,  353 

—  involvement    of    neighboring    organs, 

353,  354 

Krukenberg  tumor,  349 

lymphosarcomatous  forms,  349 

—  medullary  type,  344 

—  metastatic,  350 

—  primary  squamous  cell  epithelioma,  348 

—  prognosis,  356 

—  route  of  metastases,  352 
scirrhous  type,  345 

—  solid  type,  342 

—  symptoms,  354 

—  treatment,  355 

—  of  para-ovarian  body,  300 

—  of  portio  vaginalis,  188 

microscopic  appearance,  189 

—  sigmoid  coincident  with  uterine  fibroid, 

99 

—  of  uterine  body,  279-288 

—  —  adenocarcinomata,  primary,  279 

—  age  incidence,  280 

—  — -  appearance  and  form,  281 

cells  of  suspicious  appearance,  285 

—  cervical  metastases,  283 

—  classification,  279 

—  complications  of,  283,  284 

—  critical  review  of  treatment,  287,  288 

—  diagnosis,  284 

—  etiology,  280 

—  everting  form,  281 

—  frequency  of,  279,  280 

—  frozen  sections  necessary  at  operation, 

285 


416 


INDEX 


Carcinoma,  of  uterine  body,  hemorrhage,  284 

—  lymphatic  involvement,  282 

—  method  of  growth,  282,  283 

—  mitosis  in,  282 

—  mortality  in  vaginal  hysterectomy,  286 

—  multiple  growths,  284 

—  ovarian  and  fallopian  metastases,  283 

—  panhysterectomy,  results,  286 

—  pyometra,  284 

—  radical     abdominal     operation,     con- 

trasted with  hysterectomy,  287 

—  radium,  use  of,  288 

—  squamous  cell,  rare,  279 

—  symptoms  of,  284 

—  treatment,  285-288 

—  vaginal  hysterectomy,  285,  286 

—  vaginal  metastases,  283 

—  of  uterus,  176-215 

—  classification,  185,  186 

—  etiology,  177-183 

-  -  everting  and  inverting  combined,   191 

—  frequency,  176 

—  histology,    186 

—  inverting  type,  190 

—  metastases,  203 

—  morphology,  186 

—  squamous  cell,  187 

—  topography,   185 

—  of  vagina,  54~57 

—  appearance  and  form,  56 

—  classification,  55 

—  complicating  pregnancy,  57 

—  diagnosis  and  prognosis,  57 

—  etiology,  55 

—  frequency,  54 

—  histology,  56 

—  location,  55 

method  of  growth,  56 

—  symptoms,  57 

—  of  vulva,  20-28 

—  age  incidence,  21 

appearance  and  structure,  22 

—  causes  of  death,  24 

—  classification,  23 
death  statistics,  28 

—  diagnosis,  24 

—  etiology,  21 

—  frequency,  20 

—  lymphatic   involvement,   24 

—  method  of  extension,  24 

—  operative  technic,  27 

—  prognosis,   24 

—  pruritus  in,  24 

—  recurrences,  26 
results,  28 

—  symptoms,  24 

—  treatment,  24 

—  parasitic  theory,  178 

—  relation  to  uterine  fibroids,  93 

—  sarcomatodes,  296 


Carcinoma.     See  also  Cancer 

Cardiac  deaths  in  cases  of  uterine  fibroids, 

100 

Cardiovascular  changes  in  uterine  fibroids, 

99 

Carnotite  containing  radium,  263 
Case  histories  of  mammoth  tumors,  409-411 
Cathartics,  avoidance  of,  before  operation, 

138 
Cauliflower   masses   in   ovarian   cystadeno- 

mata,  337 
Cauterization  treatment  of  cervical  cancer, 

250 
Cautery  methods  for  cancer  of  cervix,  245- 

247 
Cellular    appearance    in    cancer    of    endo- 

metrium,  285 
Central     nervous     system,     metastases     of 

chorio-epithelioma,  313 
Cervical  adenocarcinoma,  193 
Cervical  adenomyoma,  168 
Cervical   and   fundal   carcinoma,   treatment 

contrasted,  288 
Cervical  cancer,  acetone  treatment,  249 

—  and  pyometra,  225 

—  and  tuberculosis,  225 

—  anesthetic  of  choice,  227 

—  bibliography,  278 

—  bladder  involvement,  223 

—  block  excision  indicated,  222 

—  border-line  cases,  advantages  of  radium, 

274 
treated  by  radium,  274 

—  Burnm's  operation,  241 

—  cauterization  treatment,  250 

—  choice  of  operation,  226 

—  closure    of    peritoneum    after    operation, 

234 

—  complications,  224 

—  complications,     following     radiumization 

of,  272 

—  of  operation,  236-237 

—  cross-fire  radiumization,  270-272 

—  danger    of    dilating    cervix    for    radium 

work,  270 

—  drainage  after  operation,  234 

—  extirpation,  of  glands,  234 

—  of  parametrium,  232 

—  general  health,  207 

—  high  cervical  amputation  to  be  avoided, 

247 

—  incision  of  choice,  228 

—  incision  of  posterior  peritoneum,  232    ' 

—  inoperable  cases  treated  by  radium,  275 

—  Mackenrodt's  operation,  238 

—  measures  to  combat  shock  post  operative, 

236 

—  operable,  treated  by  radium,  274 

—  operability,  225 

—  improved  by  radium,  277 


INDEX 


Cervical  cancer,  operability,  mortality,  273 

—  operation,    inadvisable    after    radiumiza- 

tion,  277 

—  separate  steps,  228 

—  without  drainage,  235    , 

—  palliative  treatment,  248-252 

—  paravaginal  operation,  242,  243 

—  Percy  method  of  cauterization,  250 

—  post-operative  treatment,  236 

—  pre-operative  radiumization,  278 

—  radical  abdominal  operation,  226 

—  radical  vaginal  operation,  results,  260 

—  radiotherapy,  262-277 

—  radiumization,  complications  of,  272 

—  technic  of,  267-272 

—  radium  supplemented  by  X-ray,  271 

—  recurrent  cases  treated  by  radium,  276 

—  removal  of  pelvic  lymph  glands,  219 

—  results   of   less  extensive  methods,  260- 

262 

—  results  of  radical  operation,  255-260 

—  results  of  radium  treatment,  272 

—  Schmitz'  work  in  accumulative  radium- 

ization, 269 

—  schools  of  radium  treatment,  268 

—  selection  of  cases  for  operation,  222 

—  stages  of  treatment,  216 

—  surgery  versus  radium,  274 

—  treatment  of  recurrences,  261 

—  ureteral    transplantation    during    opera- 

tion, 237 

—  urinary  infection  after  operation,  237 

—  vaginal  disinfection,  227 

—  vaginal  hysterectomy,  futility  of,  247 

—  results,  261 

—  venous  hemostasis  in  operation,  231 

—  Werder's  cautery  hysterectomy,  246 

—  with  double  uterus,  224 

—  with  pregnancy,  225 

Cervical  corporeal  junction,  removal  of 
fibroids,  152 

Cervical  canal,  carcinoma  of,   191 

Cervical  conditions  differentiated  from  can- 
cer, 211,  212 

Cervical  fibroids,  76 

—  technic  for,  135 

Cervical  metastases  of  uterine  cancer,  283 
Cervical  sarcoma,  293-297 

—  angiosarcomata,  295 

—  arising  from  fibromuscular  coat,  294,  295 

—  arising  from  mucosa,  293,  294 

—  carcinoma  sarcomatodes,  296 

—  cell-types,  frequency  of,  295 

—  chondrosarcomata,  295 

—  circumscribed  mucosal,  293,  294 

—  complications  of,  296 

—  diffuse  mucosal,  293 
— gr apelike  growth,  294 

—  metastases,  296 

—  method  of  extension.  296 


Cervical  sarcoma,  myxosarcomatous  types, 

295 

—  pedunculated  polyp  growth,  294 

—  special  forms  and  mixed  types,  295,  296 

—  symptoms  of,  298 

Cervical  squamous  cell  carcinoma,  194 
Cervical  carcinoma  with  fibroids,  224 
Cervical  polypi  differentiated  from  cancer, 

212 
Cervix,  carcinoma  of,  196-203 

—  incision   of,   closure  of   stump   in   supra- 

vaginal  hysterectomy,  141 

—  lipomyosarcoma  of,  295 
Child-bearing  age,   influence  on  tumors,  3 
Childhood,  case  of  vulvar  carcinoma  in,  21 
Child  of  two,  cancer  in,  184 
Chondrosarcomata,  295 
Chorio-adenoma,  303 
Choriocarcinoma,  303 
Chorio-epithelioma,  300-322 

—  age  incidence  in,  307 

—  benign  chorio-adenoma,  303 

—  bibliography,  322 

—  connection  with  pregnancy,  300 

—  development  during  gestation,  311 
-diagnosis  of,  difficulties,  316 

—  difference    of    opinion    among    surgeons, 

321 

—  differentiation  of,  317 

—  etiology  of,  306 

—  extensive  operation  advised,  322 
—  frequency  of,  305 

—  hemorrhage  in,  315 

—  histology   and   clinical   findings,   discrep-. 

ancy  between,  302 

— •  histology   at   variance   with   clinical   pic- 
ture, 305 

—  location  and  size  of  growth,  307-309 

—  location  of  growth,  307 

—  malignant  choriocarcinoma,  303 
— •  metastases,  by  blood  stream,  311 

—  wide-spread,  304 

—  microscopic  picture  of,  317 

—  mortality  statistics  in,  320 

—  ovarian  changes  associated  with  growth, 

313 

—  period   of   latency   following   pregnancy, 

310 

—  possibilities  of  radium  treatment,  322 

—  prognosis,  318 

—  rapid    soft    tissue    reformation,    pathog- 

nomonic,  318 

—  recovery  after  vaginal  metastases,  319 

—  spontaneous  cures  in,  300 

—  syncytial  endometritis,  304 

—  syncytioma,  304 

—  treatment  of,  321 

—  typical  and  atypical  forms,  302 

—  uterine,  resemblance  to  chorioma  of  tes- 

ticle, 308 


INDEX 


Chorioma,  mistaken  for  tuberculosis,  315 

—  of  testicle,  308 

—  primary  of  ovary,  Ries'  report,  309 
Chorionic  stalks,  310 
Chondroma  of  ovary,  371 

"Christian   Science"   and  mammoth  tumor, 

404 
Chromatin   in   cells,    effect   of    radium    on, 

266 

Chronic  inflammation,  precancerous,  183 
Circumscribed   sarcoma,  arising  in  uterine 

muscle,  291 

—  of  uterus,  291 

Clark's    summary   of   contra-indications    to 

radium  treatment,  121 
Clark's  views  on  treatment  cf  cervical  and 

fundal  carcinoma,  288 
Class  influence  on  cancer,  181 
Classification,     of    carcinoma,     of     uterine 

body,  279 
of  vagina,  55 

—  of  fibromyoma,  of  vagina,  51 

—  of  fibromyomata,  of  uterus,  72 

—  of  ovarian  tumors,  323,  324 

—  of  sarcoma,  of  uterus,  290 

—  of  vagina  in  adult,  63 

—  of  sweat  gland  tumors  of  vulva,  13 

—  of  uterine  carcinoma,  185,  186 

—  of  vulvar  carcinoma,  23 

—  of  vulvar  fibroma,  I 

—  of  vulvar  sarcomata,  36 

Clinical  features  of  ovarian  cancer,  352-355 
Clitoris,  adenocarcinoma  of,  32 

—  carcinoma  of,  28-32 

—  age  incidence,  30 

—  appearance,  30 

—  etiology,  29 

—  histology,  32 

—  metastases,  32 

—  symptoms,  32 

Coal  in  relation  to  cancer,  182 
Cohnheim's  theory  of  cancer,  177 
Colostrum,  with  fibroids,  107 
Coitus,  interference  with,  by  fibroma,  10 

—  interrupted  by  lipoma  of  vulva,  13 

—  obstructed  by  vaginal  cyst,  50 
Colpohyperplasia  cystica,  49 
Colpitis  vesicula  emphysematosa,  49 
Complications  of  mammoth  ovarian  tumors, 

405 

Conception,  in  case  of  mammoth  tumor,  8 
Condyloma   of    cervix    differentiated    from 

cancer,  212 
Congenital    ectropion    and   cervical    Cancer, 

211 

Connective    tissue    cell,    metaplasia     from 

muscle  cell,  293 
Constipation,  and  uterine  fibroids,  99 

—  from  fibroma,  10 

Contact  infection  in  cancer,  178 


Complications,    of    carcinoma    of    body    of 
uterus,  283,  284 

—  of  cervical  sarcoma,  296 
Corpus  luteum,  cysts  of,  326 

—  malignant  tumors  of,  377 

Corpus  uteri,  cancer  of.    See  Carcinoma  of 

Body  of  Uterus 

Cross-fire  radiumization,  270-272 
Cross-fire  X-ray  dosage  in  fibroids,  116 
Crookes'  work  in  1895,  262 
Cullen's  theory  of  adenomyoma,  164 
Curie,  work  in  1898,  262 
Cystadenomata  of  ovary,  331-340 

—  border-line  of  malignancy,  338 

—  cystadenoma  serosum,  336 

—  cyst  contents,  335 

—  histogenesis,  331-333 

—  pseudocystadenomata,  microscopic  struc- 

ture, 335 

—  pseudo  mucinous  types,  333 

—  solid  adenomata,  336 
Cystic  adenomyomata,   167 
Cystic  carcinoma  of  ovary,  345 

Cystic  contents  in  ovarian  cysts,  335    . 
Cystic  degeneration  of,  ovary,  325 

—  tumors,  10 

—  uterine  fibroids,  84 
Cystic  dermoids,  358-364 
Cystic  ovaries  and  sterility,  328 
Cystic  ovary,  in  chorioma,  314 

Cysts,  of  accessory  fallopian  tubes,  300 

—  of  hydatid  of  Morgagni,  390 

—  of  hymen,  16 

—  of  vagina,  42-51 

—  age  incidence,  43 

—  appearance  and  location,  44 

—  classification,  43 

—  diagnosis  of,  50 

—  differentiation  of,  50 

—  echinococcus,  50 

—  etiology,  43 

—  excision,  50 

—  frequency,  43 

—  Gartner's  ducts,  47 

—  gas  cysts,  49 

—  histology,  44 

—  Miiller's  ducts,  47 

—  point  of  origin,  44 

—  symptoms  of,  50 

—  types  of  cysts,  45 

—  ureteral,  48 

—  urethral,  49 

Death,  from  calcified  fibroids,  84 

Death  statistics,  in  carcinoma  of  vulva,  28 

—  in  fibroid  cases,   in 

Deformity  of  ribs  in  mammoth  tu^nor,  409 
Degeneration,  of  fibromata,  causes  of,  9 

—  of  uterine  fibromata,   80 
Denuded  areas  in  panhysterectomy,  146 


INDEX 


419 


Dermoid  cysts,  358-364 

—  age  incidence,  358 

—  appearance  and  form  of,  358 

—  atypical,  361,  362 

—  carcinomatous  degeneration,  363 

—  complicating   pregnancy,   364 

—  complications  of,  363,  364 

—  diagnosis,   365 

—  frequency,  358 

—  malignant   degeneration,   362 

—  multiple,  362 

—  of  broad   ligament,  394 

—  prognosis,  365 

—  sarcomatous  degeneration,  363 

—  symptoms,  365 

—  treatment,  365 
Dermoid  plug,  359 

Dermoid,  representing  distorted  fetal  struc- 
tures, 360 

Detached  ovarian  cyst,  382 

Developmental  anomalies,  relation  to  ovar- 
ian cancer,  341 

Diagnosis,  and  prognosis  of  adenomyoma 
of  uterus,  171 

—  of  carcinoma  of  vagina,  57 

—  of  sarcoma  of  vagina  in  adult,  66 
—  in   infancy,  62 

—  of  vulvar  carcinoma,  24 

—  and  treatment  of  fallopian  tube  tumors, 

399 

—  of  carcinoma  of  endometrium,  284 

—  of  cervical  cancer,  208,  209 

—  of  chorio-epithelioma,  316 

—  of   dermoid  cyst,  365 

—  of  fibroma  of  vulva,  10 

—  of  lipoma  of  vulva,   13 

—  of  ovarian  cancer,  355 

—  of  ovarian  cysts,  328 

—  of  ovarian  fibroids,  371 

—  of  sarcoma  of  uterus,  298 

—  of   teratoma,   368 

—  of  tumors   of  broad  ligament,  387 
Differential    diagnosis    of    uterine    fibroids, 

107 

Diffuse  sarcoma,  arising  in  uterine  muscle, 
291 

—  of  uterus,  290 

Diphtheritic  patches  of  cervix  differentiated 

from   cancer,   213 
Double  malignant  tumors,  206 
Downe's  electrothermic  clamp,  246 
Doyen's  panhysterectomy,  152 
Drainage   after  cervical  operation,  234 
Drugs  used  in  cancer  treatment,  249 
Ductus    thyrioglossus    present    in    ovarian 

thyroid,   367 

Dysmenorrhea  with  uterine  fibroids,   104 
Dyspareunia,  and  fibromyoma  of  vagina,  52 

—  in   carcinoma   of   clitoris,   32 
Dystocia  caused  by  fibroids,  158 


Early  diagnosis,  important,  in  cervical  can- 
cer, 209 

Ectopic  chorio-epithelioma,  primary,  309 
Ectopic  gestation  and  fibroids,   108 
Ectropion  congenital,  of  cervix,  211 
Edema  in  fibromata,   10 
Elephantiasis,  confused  with  lipoma,  13 
Emanations,  gaseous  properties  of,  263 
Emanuel's  tumor  classification,  I,  2 
Embolic    placental    cells,    causing    chorio- 
epithelioma,  309 
Embryoma,  356-369 

—  etiology  of,  357 

—  of  tube,  401 

Embryonic  cells,  selective  action  of  radium 

on,   265 

Emphysema  vaginae,  49 
Enchondroma  of  tube,  400 
Encysted  peritonitis   with   uterine  fibroids, 

98 

Endometritis   with  fibroid  tumor,  96 
Endometrium,  cancer   of.     See   Carcinoma 
of  Body  of  Uterus 

—  sarcoma   of.      See    Sarcoma   of   Uterine 

Body 

Endothelioma  ovarii,  375 

Endothelioma  of  cervix,  differentiated  from 
cancer,  213 

End  results  of  radical  operation  better  than 
hysterectomy,  287 

Epithelioma,  squamous  cell,  of  Bartholin's 
glands,  33 

Ergot,  use  of,   in  fibroids,    113 

Erosion  of  cervix,  differentiated  from  can- 
cer, 211 

Etiology  of,  adenomyoma  of  uterus,  163, 
164 

—  broad  ligament  tumors,  384 

—  carcinoma,  of  Bartholin's  glands,  33 

—  of   fallopian  tube,  397 

—  of  uterine   body,  280 

—  of  uterus,    177-183   • 

—  of  vagina,  55 

—  chorio-epithelioma,   306 

—  embryoma,  357 

—  fibroma  of  vulva,  2 

—  fibromyoma,  of  vagina,  51 

—  of  uterus,  70 

—  ovarian  carcinoma,  340,  341 

—  sarcoma,  of  body  of  uterus,  289 

—  of  vagina,  in  adult,  63 
—  in  infancy,  59 

—  sweat  gland  tumors  of  vulva,  14 

—  vulvar  carcinoma,  21 

Eversion     of     cervix,     differentiated     from 

cancer,  211 

Everting  carcinoma  of  uterus,    188 
Everting  form  of  carcinoma  of  uterus,  281 
Ewing's     classification    of     chorio-epitheli- 
oma, 303 


420 


INDEX 


Expectant  treatment  of  fibroids,  112-114 
Extirpation  of   glands,   in   cervical   cancer, 

234 
Eyes,  lids,  and  lashes,  in  dermoid  cysts,  360 

Fallopian  metastases  of  uterine  cancer,  283 
Fallopian  tubes,  accessory,  390 

—  tumors  of,  394-401 
adenocarcinoma,  398 

—  adenomyoma,  401 

—  benign,  of  tubal  epithelium,  395 

—  bibliography,  401 

—  carcinoma  of  tube,  396 

—  diagnosis  and  treatment,  399 

—  embryoma,  401 
enchondroma,   400 

—  fibromyomata,  400 

—  lipomata,  400 

—  lymphangioma,  400 

—  mesoblastic  growths,  401 

—  papillary  carcinoma,  398 

—  papilloma  of  tube,  395 

—  polyps  of  tubal  epithelium,  395 
secondary  carcinoma  of  tube,  400 

—  symptoms  and  treatment,  396 
Familial  incidence  of  cancer,  181 

Fatty   degeneration   of,    heart   and   uterine 
fibroid,  99 

—  uterine  fibroids,  90 

Fertile  women,  and  chorio-epitheliomata, 
306 

Fetal  ectodermal  cells,  eroding  blood  ves- 
sels, 311 

Fetal  position  changed  by  fibroids,  158 

Fetus,  distorted,  in  dermoid  cysts,  361 

—  sarcoma  of  ovary  in,  372 

—  within  a  fetus,  394 

Fibroglia,  staining  methods  for,  293 
Fibroid,  originating  sarcoma,  292,  293 
Fibroma,  and  myoma  of  ovary,  369-371 

—  of  ovary,  age  incidence,  369 
Fibromyoma,  of  broad  ligament,  391 

—  of  tube,  400 

—  of   uterus,   age   incidence,   70 

Fibroid  degeneration  during  pregnancy,  157 
Fibroid  heart,  101 
Fibroid  tumors,  origin  of,  2 
Fibroids,  and  adenocarcinomata  of  uterus, 
probable  common  origin,  284 

—  and  ectopic  gestation,  108 

—  and  placenta  previa,   160 

—  and  pregnancy,  relation  between,  162 

—  bibliography,    162 

—  bleeding  during  pregnancy,   157 

—  causing  abortion,   158 

—  causing   dystocia,    158 

—  cervical,  technic   for,   135 

—  changing  fetal  position,  158 

—  coincident  with  cancer  of  endometrium, 

283 


Fibroids,  complicating  labor,  158 

—  complicating  puerperium,    160 

—  delivery  of,  in  operation,   139 

—  effect  of  pregnancy  on,  156 

—  in  labor,  treatment,  160 

—  of    cervico-corporeal    junction    removal, 

152 

—  of  uterus,  biblography,  in 

—  diagnosis,   105 

—  symptoms  of,   102-105 

—  operation  preparation   and  technic,   137- 

139 

—  relation  to  ovarian  disease,  155 

—  relation  to  sterility,  155 

—  small,  diagnosis  of,   105 

—  submucous,  non  pedunculated,  134 

—  pedunculated,    133 

—  subperitoneal,  pedunculated,   128 

—  with  cervical  carcinoma,  224 
Fibroma,  age  influence,  3 

—  calcification  of,  10 

—  cystic  changes  of,   10 

—  degenerations  of,  9 

—  differential  diagnosis,   10 

—  edema  of,  10 

—  influence  of  pregnancy  on,  4 

—  itching   of,   IO 

—  malignant  changes  in,  10 

—  mammoth,  drawing  of,  7 

—  menstrual  influence  on,  4 

—  multiple,   pedunculated,  6 

—  of  inguinal  canal,  4 

—  mistaken    for    hernia,    10 

—  of  uterus,  fatty  degeneration,  90 

—  gross  appearance  of  sarcomatous  de- 

generation, 92 

—  hemorrhage,  102 

malignant  degeneration,  90 

—  necrosis,  88 
prognosis  of,  no 

—  red  degeneration,  89 

—  relation   to   carcinoma,   93 

—  sarcomatous  degeneration,  91 

—  of  vulva,  i-n 

—  appearance  and  size,  3 

—  classification  of,   i,  2 

—  diagnosis  of,  10 

—  etiology  of,  2,  3 

—  influence  of  trauma,  3 

—  origin  of,   I 

—  pedicle  of,  4 

—  resemblance   to   scrotum,   3 

—  statistics  of,  I 

—  symptoms    of,    10 

—  treatment  of,   n 

—  recurrence    of,    n 

—  sarcomatous  changes  of,  4,  5 
Fibromyoma,  of  uterus,  68-1  n 

—  atrophic  changes,  82 

—  blood   supply,   80 


INDEX 


421 


Fibromyoma,  of  uterus,  calcerous  degenera- 
tion, 83 
cervical  fibroids,  76 

—  classification,  72 

—  cystic  degeneration,  84 

—  definition,  68 

— degeneration,   80 

—  etiology,   70 

—  frequency,  68 

—  growth,    71 

—  histogenesis,  70 

—  histology,   79 

hyalin  degeneration,  82 

—  infection  and  suppuration,  86 

—  intramural   fibroids,   74 

—  lymph  supply,  80 

—  structure,   79 

—  submucous   fibroids,   73 

—  subserous   fibroids,   75 
—  of  vagina,  51,  52 

—  age   incidence,    51 

—  appearance   and   location,   51 

—  classification,    51 

—  diagnosis,  52 

—  etiology,  51 

—  histology,   52 

—  occurrence  with  pregnancy,  52 

—  point   of   origin,   51 

—  symptoms,  52 

—  treatment,   52 

Fibromuscular   sarcomata  of  cervix,   rarity 

of,  294 
Fibrous    reparative   change    after    radiumi- 

zation,  266 

Filters  and  screens  for  radiumization,  267 
Fistulae,  a  complication  after  cervical  ra- 
diumization, 272 

Five-year-cure  period,  as  test,  35 
Five-year  limit  of  cancer  cure,  254 
Five-year  period  in  inoperable  cervical  car- 
cinoma, 276 
Fluid    content    of    racemose    ovarian    cyst, 

339 

Fluid,    large   amount   in   uterus,   with    sar- 
coma, 296 

—  type  of,  in  mammoth  cysts,  406 
Follicle  cysts  of  ovary,  325 
Folliculoma  malignum,  347 
Fractional  X-ray  dosage  in  fibroids,   115 
Frequency,  of  carcinoma,  of  uterine  body, 

279 

—  of  uterus,  176 

—  of  ovary,  340 

—  of  vagina,   54 

—  of  vulva,  20 

—  of  chorio-epithelioma,  305 

—  of  dermoid  cysts,  358 

—  of  fibromyoma  of  uterus,  68 

—  of  ovarian  tumors,  324 


Frequency,  of  para-ovarian  cysts,  388 

—  of  sarcoma  of  uterine  body,  288-289 

—  of  teratoma,  365 

—  of  vulvar  sarcomata,  36 
Fromme,  views  on  tumors,  2 

Frozen  sections  necessary  at  operation,  285 
Fuel  consumption  and  cancer,  182 
Fundal   and  cervical   carcinoma,   treatment 
contrasted,  288 

Gartner's  ducts,  cyst  of,  388 
Gall-bladder  metastases,  204 
Gamma  rays  of  radium,  264 
Gangrene   of   tumors,   10 
Genitalia,  pigmented  cells  of,  38 
Germinal    epithelium,    originating    ovarian 

cysts,  332 

Gestation,    development   of   chorio-epitheli- 
oma during,  311 

Girl,  16  years,  wfth  io8-pound  tumor,  405 
Glandular   masses    differentiated    from    tu- 
mor, ii 
Gloves,  change  of,  during  panhysterectomy, 

144 

Goffe's  work  on  hysterectomy,  137 
Gonorrheal      infection,      and      bartholinian 

gland  carcinoma,  33 
Grapelike  cystoma  of  ovary,  339 
Grapelike  sarcoma  of  cervix,  294 
Gynecology,  use  of  radium  tubes  in,  267 

Hair,  color  of,  in  dermoid  cysts,  366 
• —  covering  tumors,  4 

Heart,  and  blood  vessels,  effect  of  uterine 
fibroids  on,  99 

—  changes   in   uterine  fibroma,   primary  or 

secondary,  101 

—  metastases,  204 

Hematomata,  as  cause  of  tumors,  2 
Hematometra  in  uterine  sarcoma,  296 
Hematosalpinx   complicating   fibroids,   97 
Hemiplegia  from  spinal  cord  chorioma,  315 
Hemoglobin   diminution  in   uterine   fibroid, 

105 
Hemorrhage,   in   adenomyoma,   169 

—  in  carcinoma  of  cervix,  206 

—  in    chorio-epithelioma,    315 

—  in  uterine  fibroids,   102 

—  type  of,   in  cancer  of  endometrium,  284 
Hemorrhoids  and  uterine  fibroids,  09 
Hepatic    metastases    of    chorio-epithelioma, 

3I3,. 
Hereditary  influence  on  uterine  fibroids,  70 

Heredity  and  cancer,  180 
Hermaphroditism,  and  tumor  growth,  377, 
378 

—  really  a  tumor,  10 

Hernia,  inguinal,  really  tumor,  10 
Histogenesis    of    cystadenomata    of    ovary, 
331-333 


422 


INDEX 


Histology     of,     adenomyoma     of     uterus, 
167 

—  cancer  of  uterus,  186 

—  carcinoma  of  vagina,  56 

—  fibromyoma   of  uterus,    70 

—  hydradenomata,  15 

—  ovarian  fibromata,  370 

—  para-ovarian  cysts,  389 

—  sarcoma  of  vagina,  in  adult,  65 

—  in  infancy,  61 

—  uterine  fibroids,  79 

Hyaline  degeneration  of,  tumors,  10 

—  uterine  fibroids,  82 
Hydatid  of  Morgagni,  388 

—  cysts  of,  390 

Hydatiform    degeneration    of    chorion    in, 

abortion,  307 

Hyda^idiform  mole,  predisposing  to  chorio- 
epitheliomata,  306 

—  relation  to  chorio-epitrfelioma,  300 
Hydradenoma,  histology  of,  15 

—  tubulare,   13 

Hydrastis  canadiensis  in  fibroid  cases,  113 
Hydrocele   muliebrum,   differentiated   from 

tumor,  10 

Hydronephrosis     and     pyonephrosis,     with 
uterine  fibroids,  101 

—  from  sarcomatous  pressure,  296 
Hydrops,  folliculi,  325 
Hydrosalpinx  complicating  fibroids,  97 

—  from  tubal  growth,  395 
Hydro-ureter  with  uterine  fibroids,  99 
Hymen,  cysts  of,  16 

—  appearance,  17 

—  sarcoma  of,  38 

Hypertrophy      of      cervix,      differentiated 

from  cancer,  211 
Hysterectomy,  abdominal,   for  fibroids,   136 

—  preferable   for   nonpedunculated   submu- 

cous  fibroids,  135 

—  vaginal,   in   cancer   of   endometrium,    re- 

.sults,  285,  286 

—  with  Werder's  cautery,  246 

Immunity  to  cancer,  179 
Incision   of   choice   in   abdominal   myomec- 
tomy,  128 

—  in  cervical  cancer,  228 
Infancy,  case  of  tumor  in,  3 

—  sarcoma  of  uterus  in,  290 

—  sarcoma  of  vagina  in,  58-63 
Infection    and    suppuration    of    uterine    fi- 
broids, 86 

Infectiousness  of  carcinoma,  marital,  55 
Inguinal  canal,  tumors  of,  4 
Inguinal  hernia,  really  tumor,   10 

—  simulated  by  lipoma,  n 
Inoperable  cervical  cancer,  208 

—  palliated  by  radium,  275 
Insanity  and  uterine  fibroids,   102 


Inspection   for   uterine  fibroids,    106 
Instruments,   change  of   during  panhyster- 

ectomy,   145 

Intensive  X-ray  dosage  in  fibroids,  115 
Internal  secretion  in  ovarian  thyroid,  367 
Interstitial  fibroids,   treatment,    135 
Interstitial    superitoneal    fibroids,    removal, 

130 

Intestinal  metastases,  204 
Intestinal    obstruction    from    fibrosis    after 

radiumization,  272 
Intramural  uterine  fibroids,  74 
Inversion  of  uterus  in  nulliparae,  297 
Inverting  carcinoma,   191 
lodin  in  struma,  ovarii,  367 
Itching,  in  carcinoma  of  clitoris,  32 

—  in  fibromata,  10 

—  in   sarcoma  of  vulva,   40 

Jackson's  zinc  chlorid  treatment  for  can- 
cer, 249 

Karyorrhexis,    104 

Kelly's  left  to  right  supravaginal  hysterec- 
tomy, 148 

Kelly's  method  of  tumor  bisection,  147,  152 

Kelly's  statistics  of  radium  treatment  of 
fibroids,  122 

Kewisch,  views  on  tumors,  2 

Kidney,  changes,  with  uterine  fibroids,   101 

—  and  ureter  double,  48 

—  metastases,  204 

KirschofFs   case   of  vulvar  fibroma,  4 
Kraurosis,  relation  to  carcinoma  of  vulva, 

22 

Krukenberg  tumor,  349 
Kuestner's  law  of  rotation  of  tumors,  380 

Labium,  majus,   tumors   of,  2 

—  minus,  tumors  of,  2 

—  tumors  of,  weight,  5 

Labor,  complicated  by  fibroids,   158 

—  obstructed  by  vaginal  cyst,  50 
Lacerations    of    the    cervix,    differentiated 

from  cancer,  212 

Langhans'  cells  in  chorio-epithelioma,  300 
Larvnx   and   vocal   cords   in   dermoid   cyst, 

36l 

"Leiomyoma  malin,"  289 
Leonard's  table  of  tumors,  2 
Leukoplakia,     relation     to     carcinoma     of 

vulva,  22 
Leukorrhea   in   adenomyoma,    169 

—  in  cervical  carcinoma,  206 

—  in  uterine  fibroids,   105 

Lipoma,  confused  with  elephantiasis,  13 

—  of  broad  ligament,  393 

—  of  tube,  400 

—  of  vulva,  11-13 
appearance  of,  II 


INDEX 


423 


Lipoma,  of  vulva,  diagnosis  of,  13 

—  growth  of,   12 

hemorrhage  of,  12 

statistics  of,   n 

symptoms  of,  12 

treatment,   13 

—  simulating  inguinal  hernia,  n 
Lipomyomata,   90 
Lipomyosarcoma   of   cervix,  295 
Liver  metastases,  204 

Location  of,  carcinoma  of  vagina,  55 

—  sarcoma  of  vagina  in  adult,  65 
Locomotion,  interference  with,  by  fibroma, 

10 
Lumbar  anesthesia  in  removal  of  cervical 

cancer,  227 
Lung  metastases,  204 
Lutein    cysts,    multilocular,    with    hydatidi- 

form  mole,  327 

"Lymphangioma  cystomatosum,"  375 
• —  of  ovary,  372 

—  of  tube,  400 

Lymphangiectases  of  tumors,   10 
Lymphatic    involvement    in    carcinoma    of 

cervix,   199 

—  of  uterine  body,  282 
of  vulva,  24 

—  in  ovarian  carcinoma,  353 

Lymph  glands  in  cervical  cancer,  removal 

indicated,  221 
Lymph   nodes    involved    in   uterine   cancer, 

200 

Lymphocytic  control  and  cancer,  179 
Lymphosarcomata  of  cervix,  295 


Mackenrodt's    operation,    complications   of, 
241 

—  for  cervical  cancer,  238 
Malignancy  possible  in  vulvar  sweat  gland 

tumors,    16 
Malignant  tumors,  double,  296 

—  of  outlet,  20-41 

—  of  vagina,  54-67 

Mallory's     staining    methods     for    myoglia 

and  fibroglia,  293 
Mammoth  neoplasms,  6 
Mammoth  ovarian  tumors,  403-12 

—  complications,   405 

—  geographical  distribution,  403 
• — prognosis  of,  407 

—  resume  of  cases,  409 

—  symptoms  of,  407 

. —  tapping  of  tumor,  408 

—  type  of  fluid,  406 

Mammoth  pseudomucinous  cystadenoma  of 
ovary,  333 

Mammoth  sarcomata,  submucous  and  sub- 
serous,  292 

Mammoth  tumors,  method  of  weighing,  404 


Marchand's  theory  as  to  chorionic  epi- 
thelioma,  301 

Marital  infection  in  carcinoma,  55,  178 

Massive  radium  dosage,  Memorial  Insti- 
tute work,  269 

Mayo  clinic,  results  of  radium  treatment  of 
fibroids,  122 

—  statistics  on  myomectomy,   126 
Meat  eaters  and  cancer,  182 
Medication   in   fibroid   treatment,    113 
Medullary  carcinoma,  of  ovary,  344 

—  of  vulva,  23 

Melanemia,  in  melanotic  sarcoma,  40 
Melanocarcinoma  of  vulva,  23 
Melanosarcoma,   colorless,   primary,   36 

—  metastasizing,  295 

—  of  ovary,  373 

—  uterine,  291 

Melanuria  in  melanotic  sarcoma,  40 
Memorial    Institute,    New    York,    radium 

work,  269 
Menopause  postponed  by  fibroids,   105 

—  relation  to  vulvar  carcinoma,  22 
Menorrhagia  and   ovarian   tumor,   378 

—  uterine   fibroids,    102 

Menses,  cessation  of,  in  ovarian  carcinoma, 

354 
Menstruation,  influence  of,  on  tumors,  4 

—  premature  and  ovarian  tumor,  378 
Mesoblastic  tumors  of  tube,  401 
Mesodermal  development  of  teratoma,  368 
Mesonephric  tumors  of  ovary,  377 
Metabolic  influence  of  radium,  265 
Metaplasia  in  sarcomatous  changes,  293 
Metastases,    general,    from   uterine    carcin- 
oma, 203-5 

—  in   carcinoma   of   clitoris,   32 
of   uterine   body,   282 

-  —  of  vulva,  24 

—  in  ovarian  sarcoma,  374 

Method  6f  growth,  of  carcinoma,  of  uter- 
ine body,  282-283 

—  of  vagina,  56 

—  of  sarcoma  of  vagina  in  infancy,  61 

—  in   adult,  66 

—  of  vulvar  carcinoma,  24 
Millicurie  hours  in   radiumization,  267 
Milligrams  of  radium  dosage,  267 
Mitoses  in  carcinoma  of  uterine  body,  282 
Mixed  tumors  of  tube,  401 

Alohr's  statistics  of  fibroid  cases,   117 
Morcellation,  obsolete,  135 
Morestin,  views  on  tumors,  2 
Morphology  of  cancer  of  uterus,    186 
Mortality  and  operability  in  cervical  can- 
cer, 275 

—  in  endothelioma  oyarii,  376 

—  primary,  in  vaginal  hysterectomy,  in  can- 

cer of  endometrium,  286 

—  statistics  of  mammoth  tumors,  411,  412 


424 


INDEX 


Multiple  cancers  of  endometrium,  284 

Multiple  dermoids,  362 

Muscle  cell,  metaplasia  to  connective  tissue 

type,  293 

Myoglia,  staining  method  for,  293 
Myoma  cell  and  X-ray  influence,  116 
Myomectomy  during  pregnancy,  160 
-  incision  of  choice,  128 

—  indications  and  contraindications,  124 

—  mortality  statistics,   125 

—  technic  of,  126 

—  vaginal,  132 

—  with  proper  peritonealization,   131 
Myxofibroma,   10 

Myxoma  of  ovary,  371 

Myxomatous  degeneration  of  surface  papil- 
lae of  ovary,  339 
Myxosarcomata  of  cervix,  295 

—  ovary,  373 

Naevi,  pigmented,  as  origin  of  sarcoma,  38 

Necrobiosis,  89 

Necrosis  of  uterine  fibroids,  88 

Negro    women,     susceptibility    to     uterine 

fibroids,  69 
Nervous    symptoms    with    uterine    fibroids, 

IOI-IO2 

Neuroma  of  vulva,  18 
Newborn  child,  fibroma  in,  70 

—  fibromyoma  of  vagina  in,  51 

—  rhabdomyoma  of  broad  ligament,  385 

—  sarcoma  in,  59 

—  tumor  in,  3 

Nitrogen   balance   disturbance   and   cancer, 

180 

Nonproliferating  cysts  of  ovary,  324-330 
Non-radical  operative  treatment  in  fibroids, 

114 
Nulliparae,  chorio-epitheliomata  in,  306 

—  inversion  of  uterus  in,  297 

Omental    hernia    irreducible,    differentiated 

from  tumor,  10 

One-child  sterility  and  fibroids,  156 
Oophorectomy  and  tumor  atrophy,  82 
Operation    for    cervical   cancer,    choice    of, 
226 

—  radical  type,  222 

—  selection  of  cases,  222 

—  separate  steps,  228 

Operative  centra-indications  in  fibroids,  124 
Operative  indications  in  fibroids,  123 
Organ  of  Rosenmiiller,  tumors  of,  390 
Origin  and  location  of  sarcoma  of  vagina 

in  infancy,  59 
Ostia,  cysts  of,  390 
Ovarian,  changes  in  chorioma,  313-314 

—  chorioma,  primary,  309 

—  cystadenomata,  331-340 

—  cyst  with  fibroids,  98 


Ovarian,  disease  and  sterility,  155 

—  enchondromata,  368 

—  fibromata,  diagnosis,  371 

—  histology,  370 

—  metastases  of  uterine  cancer,  283 

—  pregnancy,  causing  chorioma,  309 

—  removal,  pros  and  cons,  137 

—  sarcoma,  primary,  372 

—  prognosis,  375 

—  symptoms,  375 

—  sensitiveness  to  radium,  265 

—  stone,  370 

—  thyroid,  367 

—  tumors,  323-381 

—  adenocarcinoma  papillare,  345 

—  pseudomucinosum,  345 

—  adenofibromata,  340 

—  adenomata  miscellaneous,  340 

—  adenomyoma,  376 

—  angiosarcoma,  374 

—  bibliography,  382 

—  blood  cysts  of  ovary,  327 

—  carcinomata,  340-381 

—  classification  of,  323 

—  corpus  luteum  cysts,  326 

—  cystadenomata,  331-340 

—  embryoma,  356-369 

—  endothelioma  ovarii,  375 

—  fibroma  and  myoma,  369-371 

—  follicle  cysts,  325 

—  f olliculoma  malignum,  347 

—  frequency,  324 

—  general  symptoms  of,  378-382 

—  Krukenberg  tumor,  349 

—  large,  without  symptoms,  379 

—  lymphangiomata,  372 

—  malignant  growths  of  corpus  luteum, 

377 

—  mammoth,  403-412 

—  medullary  carcinoma,  344 

—  melanosarcoma,  373 

—  mesonephric  tumors,  377 

—  rnetastatic  carcinoma,  350 

—  metastatic  sarcoma,  374 

—  myosarcoma,  373 

—  myxomatous  degeneration  of   surface 

papillae,  3,  39 

—  myxosarcoma,  373 

—  neoformations,  331-381 

—  nonproliferating  cysts,  324-330 

—  symptoms,  328 

—  osteoma  and  chondroma,  371 

—  ovotestis  tumors,  377 

—  parenchymatogenous  types,  331,  352 

—  perithelioma,  374 

—  precocious  sex  development,  378 

—  primary    squamous    cell    epithelioma, 

348 

—  pseudomucinous  cystadenoma,  333 
racemose  ovarian  cysts,  339 


INDEX 


425 


Ovarian    tumors,    rectal    examination    im- 
portant, 328 
removal  of  ovary,  330 

—  and  tube,  330 

—  resection  of  ovary,  329 

—  retention  cysts  not  derived  from  fol- 

licles, 327 

—  puncture  of,  329 

—  sarcoma,  372 

—  scirrhus  carcinoma,  345 

—  —  simple  follicle  cysts,  325 

—  small  cystic  degeneration  of  ovary,  325 

—  stromatogenous  tumors,  369-381 

—  symptoms  in  carcinoma  of  ovary,  354 

—  torsion  of,  379 

—  treatment  of  cysts,  329 

—  tubo-ovarian  cysts,  327 

Ovaries,      accessory,      producing      dermoid 
cysts,  359 

—  effects  of  fibroids  on,  97 
"Ovarium  gyratum,"  370 
Ovotestis  tumors,  377 
Outlet,  benign  tumors  of,  1-19 
. —  malignant  tumors  of,  20-41 

Packs,  counted  at  operation,  141 

Paget's  disease,   resemblance  to  carcinoma 

of  clitoris,  31 
Pain,  in  adenomyoma,  169 

—  in  sarcoma  of  uterus,  297 

—  in  uterine  fibroids,   105 

Palliative  treatment  of  cervical  cancer,  248- 

252 

Palpation  for  uterine  fibroids,  107 
Pancreatic  compression   in   ovarian   tumor, 

379 
Panhysterectomy,  136 

—  atypical   operation   in   complicated   cases, 

145 

—  cancer  of  endometrium,  results,  286 

—  denuded  areas,  146 

—  Doyen's  method,  152 

—  Kelly's  tumor  bisection  method,  147 

—  Pryor's  method,  148 

—  sigmoid  colon  used  for  peritonealization, 

ISO 

—  uncomplicated  fibroid  cases,  142 
Papillary  carcinoma  of  fallopian  tube,  308 
Papillary  pseudomucinous  adenomata,  334 
Papilloma,  of  ovary,  338 

—  of  tubal  epithelium,  395 

Paralytic  ileus  from  torsion  of  tumor,  381 
Parametrium   and  paracolpium,   freeing  of, 
in  Mackenrodt's  operation,  239 

—  extirpation  of,  in  cervical  cancer,  232 

—  involvement  of,  in  cancer,  202 

—  in  carcinoma  of  uterine  body,  283 

—  radiumization  of,  271 
Para-ovarian  cysts,  frequency  of,  388 

—  histology  of,  389 


Para-ovarian    cysts,    symptoms    and    treat- 
ment, 389 

Para-ovarian  organ,  function  of,  388 
Para-ovarian  tumors,  388-390 

—  miscellaneous,  390 
Parasitic  theory  of  cancer,  178 
Paravaginal  operation,  drainage  in,  244 

—  in  cervical  cancer,  242,  243 
Parenchymatogenous  tumors  of  ovary,  331- 

352 
Parity,  and  submucous  growths,  156 

—  in  clitoric  carcinoma,  30 

Patient,  preparation  of,  for  operation,  138 
Pedunculated    fibroids,     subperitoneal,    re- 
moval, 128 

—  submucous,   133 

Pelvic  adhesions  with  fibroids,  97 
Pelvic  bone  metatases,  204  .  • 

Pelvic  connective  tissue,  origin  of  fibroma, 

I 
Pelvic  inflammatory   disease   contra-indica- 

tion  to  radium  treatment,  120 
Pelvic  inflammatory    masses    differentiated 

from   fibroid,   no 
Pelvic  lymph    glands,    removal    in    cervical 

cancer,  219 
Pelvic  organs,  effects  of  uterine  fibroids  on, 

98 

Pelvic-peritonitis  and  adenomyoma,  171 
Penetrability  of  radium  rays,  264 
Percussion  for  uterine  fibroids,  107 
Percy  method  of  cauterization,  250 
Perineum,  tumors  of,  2 
Perithelioma,  of  ovary,  374 

—  of  tube,  401 

Peritoneal  closure,  after  cervical  operation, 

234 

Peritonealization  after  myomectomy,  131 
Pessaries,  causing  carcinoma,  55 
Pigmented  cells  of  external  genitalia,  38 
Pigmented  naevi,  as  origin  of  sarcoma  of 
•  vulva,  38 

Pitch-blende,  from  mines,  263 
Placenta  previa  and  fibroids,  160 
Polyp,  of  tubal  epithelium,  395 

—  placental,  malignant,  303 
Post-operative     treatment,     after     cervical 

operation,  236 

Postponement    of    menopause,    due    to    fi- 
broids, 105 

Precancerous  chronic  inflammation,  183 
Pregnancy,  and  cervical  cancer,  225 

—  and  fibroids,  relation  between,  155-162 

—  stastistics,  161 

—  and  ovarian  carcinoma,  355 

—  chorionic    growth    present,    before    ter- 

mination of,  311 

—  complicated,  with  carcinoma  of  vagina,  57 

—  with  dermoid  cyst,  364 

—  confused  with  fibroids,  108 


INDEX 


Pregnancy,  influence  of,  on  tumors,  4,  156 

—  obstruction   with  fibroma  of   vagina,   52 

—  relation  to  cancer  of  uterine  body,  280 

—  relation  to  chorio-epithelioma,  300 

—  signs  of,  with  ovarian  tumor,  378 

—  simulated  by  tumor,  75 
Preparation  of  patient  for  operation,  138 
Pressure  symptoms  in  uterine  fibroids,  104 
Primary  ectopic  chorio-epithelioma,  309 
Primary  sarcoma  of  vulva,  rarity  of,  36 
Proctitis,  following  radiumization,  272 
Prognosis  of,  carcinoma  of  ovary,  356 

—  cervical  cancer,  213 
-^—chorio-epithelioma,  318 

—  mammoth  tumors,  407 

—  ovarian  fibromata,  371 

—  teratoma,  368 

—  uterine  fibroids,  no 

Protoplasmic  enzymes,  action  of  radium  on, 

265 

Pruritus,    importance    of,    in    vulvar    car- 
cinoma, 24 

—  predisposing  to  vulvar  carcinoma,  22 
Pryor's  panhysterectomy,  148,  149 
Psammoma,  337 

Pseudomucin,  335 

Puerperium  complicated  by  fibroids,  160 

Pulmonary  metastases  of  chorio-epitheli- 
oma, 311 

Pulmonary  veins,  sarcomatous  emboli  in, 
296 

Purgatives,   avoided   before   operation,    138 

Purin  free  diet  in  cancer,  249 

Pyometra,  following  radiumization,  272 

—  in  cervical  cancer,  225 

—  in  uterine  sarcoma,  206 
Pyosalpinx  complicating  fibroids,  97 

Racial  incidence,  of  cancer,  182 

—  of  uterine  fibroids,  69 

Radical  abdominal  operation  compared  with 
hysterectomy,  in  carcinoma  of  uterine 
body,  287 

Radical  operation  for  cervical  cancer  re- 
sults, 255-260 

Radical  vaginal  operation,  results,  260 

Radio-active  substances,  262 

—  where  found,  263 

Radiotherapy  in  treatment  of  fibroids,   115 
Radium,  accumulative  effect,  advocates  of, 
268 

—  acquired  resistance  to,  266 

—  action  of,  264 

—  action  on  protoplasmic  enzymes,  265 

—  advantages  in  borderline  cases,  274 

—  Alpha  rays,  264 

—  and  surgery  statistically  compared,  274 

—  beta  rays,  264 

—  dissemination  of,  in  nature,  262 

—  dosage,  cross  fire  work,  270 


Radium,  dosage,  physiologic  effect  of,  267 

—  emanations,  gaseous  properties,  263 

—  filters  and  screens,  use  of,  267 

—  gamma  rays,  264 
efficiency  of,  266 

—  gram   of,    and   curie   of   emanation,   has 

equal  gamma  activity,  267 

—  massive  dosage,  advocates  of,  268 

—  Memorial  Institute  School  in  New  York, 

269,  270 

—  metabolic  influence,  265 

—  microscopic  effect  on  tissues,  266 

—  palliative  in  inoperable  cases,  275 

—  pioneer  workers,  264 

—  possibilities  of,  in  chorio-epithelioma,  322 

—  rays,  and  emanations,  263 

—  penetrability  of,  264 

—  types  of,  263 

—  velocity  of,  264 

—  salts,  263 

—  and  emanations,  measurement  of,  267 

—  Schmitz'    work    in    accumulative    dosage, 

269 

—  secondary  rays,  268 

—  selective  action  on  pathologic  cells,  265 

—  sensitivity  of  cells  to,  265 

—  technic  of  application,  267-272 

—  treatment,    Clark's   summary   of    contra- 

indications, 121 

—  in  carcinoma  of  vulva,  28 

—  of  cervical  cancer,  results,  272-278 

—  —  of  fibroids,  115 

—  indications    and    contra-indications, 

1 20 

—  results,  122 

—  preliminary  to  operation,  278 
supplemented  by  X-ray,  271,  272 

—  technic  of  application,  121 

—  tubes,  use  in  gynecology,  267 

—  unsatisfactory  in  recurrent  cases,  276 

—  use  in  cancer  of  uterine  body,  288 

—  variations  in  sensitivity  of  cells,  265 

—  work  in  cervical  cancer,  danger  of  cer- 

vical dilatation,  270 
Radiumization,  complications  of,  272 

—  fibrous  reparative  change  after,  266 

—  results,  four  classes  of  cases,  274 

—  borderline,  274,  275 

—  inoperable,  275,  276 

—  operable,  274 

—  recurrences,  276 
"Rayons  de  Sagnac,"  268 

Rectal    examination    important    in    ovarian 

cysts,  328 

Rectal  prolapse  and  uterine  fibroid,  99 
Rectovaginal  septum,  adenomyoma  of,  172 

—  tumors  of,  2 

Rectum,  effects  of  uterine  fibroids  on,  99 

—  involved  in  carcinoma  of  cervix,  199 
"Recurrent  fibroids"   really  sarcoma,  292 


INDEX 


427 


Red  degeneration  of  uterine  fibroids,  89 
Renal  toxic  effects  in  fibroid  tumors,  101 
Resection  of  ovary,  329 
Results  tabulated  in  mammoth  tumors,  411, 

412 
Retained  placenta  with  necrosis,  simulating 

cervical  cancer,  213 
Retention  cysts,  puncture  of,  329 
Retention  ovarian  cysts,  327 
Rhabdomyoma  of  broad  ligament  in  new- 
born child,  385 
Rhabdomyosarcoma,  292-295 
Rice  water  discharge  in  sarcoma,  297 
Roentgen  ray  treatment  of  fibroids,  115 
Round  ligament,  extraperitoneal  tumors  of, 
2 

—  origin  of  fibromata,  I 

—  See  also  Broad  Ligament  Tumors 
Rous'  work  on  cancer,  178 

Rubber  dam,  in  abdominal  operations,  139 

—  in  peritoneal  operations,  128 
Rudimentary  viscera  in  dermoid  cysts,  361 

Salpingitis,  complicating  fibroids,  97 

—  preceding  growths  of  tube,  395 
Sanguinous  discharge  after  menopause,  im- 
portance of,  284 

Sarcoma,    and    fibroids,    differentiation    by 
Mallory's  staining  methods,  293 

—  associated  with  fibroids,  no 

—  botryoids,  57,  60,  294 

—  from  adenomyomatous  tissue,  169 

—  from  dermoid  cyst,  363 

—  histogenesis  of  metaplasia  from  fibroid, 

293 

—  in  infancy  and  in  adults,  differentiation, 

58 

—  of  broad  ligament,  393 

—  of  cervix,  293-297 

—  arising   from   the   fibromuscular   coat, 

294,  295 

—  differentiated  from  carcinoma,  213 

—  of  endometrium,  symptoms  of,  298 

—  of  ovary,  372 

—  of  uterine  body,  288-299 
—  age  incidence,  290 

—  arising  in  mucosa,  290 

—  arising  in   muscle,   circumscribed,  pri- 

mary, 291 
—  diffuse,  primary,  291 

—  arising   from    preexisting   fibroid,   292 

—  circumscribed  type,  291 

—  classification,  290 

—  consistency  of,  292 

—  diffuse  type,  290 

—  etiology,  289 

—  frequency,  288,  289 

—  histogenesis  and  metaplasia,  293 

—  location  of  tumor,  290 
melanotic  types,  291 


Sarcoma  of  uterine  body,  rarity  of  reports 

in  literature,  288 
-  "recurrent  fibroids"  really  sarcoma,  292 

—  rhabdomyosarcoma,  292 

submucous  and  subserous  forms,  enor- 
mous size  of,  292 

—  telangiectasis  in,  292 

—  of  uterine  muscle,  291 

—  of  uterine  wall,  297,  298 

—  of  uterus,  bibliography,  299 

—  diagnosis,  298 

—  pain  and  hemorrhage,  297 

—  prognosis  of,  298 

—  radium  indications,  299 

—  recurrences,  299 

—  symptoms,  297 

—  treatment,  299 

—  of  vagina,  57-67 

—  classification,  58 

—  in  adult,  63-67 

—  age  incidence,  63 

—  appearance  and  form,  64 

—  bibliography,  67 

—  classification,  63 

—  diagnosis  and  prognosis,  66,  67 

—  etiology,  63 

—  histology,  65 

—  method  of  growth,  65 

—  symptoms,  66 

—  treatment,  67 

—  in  infancy,  58-63 

—  age  incidence,  59 

—  appearance  and  form,  60 

—  diagnosis  and  prognosis,  62 

—  etiology,  59 

—  frequency,  58 

—  growth,  61 

—  histology,  61 

—  origin  and  location,  59 

—  symptoms,  62 

—  treatment,  62,  63 

—  of  vulva,  36-41 

—  age  incidence,  37 

—  appearance,  38 

—  bibliography  of,  41 

—  classification  of,  36 

—  clinical  picture,  40 

—  etiology,  37 

—  frequency,  36 

—  metastases,  40 

—  point  of  origin,  38 

—  prognosis,  40 

—  symptoms  of,  40 
Sarcomatous  changes,  in  fibromata,  4,  5 

—  in  tumors,  10 

Sarcomatous    degeneration    of    uterine    fi- 
broids 91 

"Sarcophagus  for  decadent  tumor,"  120 
Schmitz'  work,  in  accumulative  radiumiza- 
tion,  269 


428 


INDEX 


Schauta's  work,  on  pelvic  lymph  glands,  220 
Scirrhus  carcinoma  of  ovary,  343-345 

—  of  vulva,  23 

Scrotum,  resemblance  to  tumors,  3 
Secondary  cancer  of  uterus,  rare,   185 
Secondary  radium  rays,  268 
Selective   action   of   radium    on  pathologic 

cells,  264 

"Seminomata,"  349 

Sensitivity  variations  of  cells  to  radium,  265 
Sessile,  subperitoneal  fibroids,  removal,  130 
Sex  characteristics,  changes  in,  in  hyper- 

nephroma,  377 

Sexual  development,  premature,  and  ova- 
rian tumor,  378 

Shock,  measures  to  combat,  236 
Sigmoid   colon    used    for  peritonealization, 

150 

Skin  metastases,  204 
Sleep,  essential  before  operation,  138 
Slye's  experiments  in  mouse  cancer,  178 
Sodium  chlorid  excess  in  cancer,  180 
Solid  tumors  of  broad  ligament,  391 
Somnolence  in  ovarian  carcinoma,  355 
Species  in  relation  to  cancer,  180 
Spinal  cord,  site  of  metastases  of  chorio- 

epithelioma,  313 

Splenic  extract  versus  cancer,  179 
Spontaneous    cures    in    chorio-epithelioma, 

302 

Spontaneous  detorsion  of  tumors,  381 
Squamous-cell     carcinoma,     of     body     of 

uterus,  192 
rarity  of,  279 

—  of  uterus,  187 

Staining  methods  for  myoglia  and  fibroglia, 

293 
Sterility,  and  cystic  ovaries,  328 

—  and  ovarian  tumor,  378 

—  influence  on  uterine  fibroids,  71 

—  relation  to  fibroids,  155 

—  statistics  on,  155 

Stimson's  work  on  hysterectomy,  137 
Stomach  metastases,  204 
Stromatogenous  tumors  of  ovary,  369-381 
Struma  ovarii,  367,  368 
Submucous  adenomyoma,  168 
Submucous  fibroids,  73 

—  differentiated  from  cancer  of  cervix,  212 

—  nonpedunculated,  134 

—  pedunculated,  133 
Submucous  growths  and  parity,  156 
Subperitoneal  and  intraligamentous  adeno- 
myoma, 167 

Subperitoneal  fibroids,  treatment,  135 

Subperitoneal  pedunculated  fibroids,  re- 
moval, 128 

Subperitoneal  sessile  and  interstitial  tumors 
removal,  130 

Subserous  uterine  fibroids,  75 


Supravaginal  hysterectomy,  136 

—  in  uncomplicated  cases,  137,  138 

—  Kelt's  left  to  right  method,  148 

—  with  normal  adnexae,  142 

—  with  removal  of  adnexa,  140 

Surgical  menopause,  relation  to  carcinoma 
of  vulva,  22 

Surgical  technic  in  operations  for  carcin- 
oma of  vulva,  27 

Sweat  gland  tumors  of  the  vulva,  13-17 

—  appearance  and  size  of,  15 

—  classification  of,  13 

—  etiology,  14 

—  histology  of,  15 

—  question  of  malignancy,  16 

—  treatment  of,  16 

Symptoms  of,  adenomyoma  of  rectovaginal 
septum,  173 

—  broad  ligament  tumors,  387 

—  carcinoma,  of  cervix    205,  206 

—  of  clitoris,  32 

—  of  ovary,  354 

—  of  uterine  body,  284 

—  chorio-epithelioma,  315 

—  dermoid  cyst,  365 

—  fibroma  of  vulva,  10,   n 

—  fibromyoma  of  vagina,   52 

—  lipoma  of  vulva,  12 

—  mammoth  tumors,  407 

—  nonprolif crating  cysts  of  ovary,  328 

—  ovarian  fibroma,  370 

—  ovarian  tumors,  general,  378-382 

—  para-ovarian  cysts,  389 

—  sarcoma  of  vagina,  in  adult,  66 
in  infancy,  62 

—  teratoma,  368 

—  tubal  growths,  396 

—  vulvar  carcinoma,  24 

Syncytial  cells  in  chorio-epithelioma,  300 

Syncytial  endometritis,  304 

Syncytioma,  304 

Syphilis  of  cervix,  differentiated  from  can- 
cer, 212 

Syphiloma,  differentiated  from  carcinoma 
of  vulva,  24 

Systemic  disease  contra-indicating  opera- 
tion, 224 

Tapping  of  mammoth  cysts,  408 
Taussig's  statistics  of  tumors,  2 
Teacher's     monograph    on    chorio-epitheli- 
oma, 302 

Teeth  in  dermoid  cysts,  360 
Telangiectasic  sarcomata  of  uterus,  292 
Teratoma,  364-369 

—  age  incidence,  365 

—  confusion  with  chorio-epithelioma,  308 

—  diagnosis,  368 

—  frequency,   365 

—  prognosis,  368 


INDEX 


429 


Teratoma,  structure  of,  366 

—  symptoms,  368 

—  treatment  of,  368 
Teratomatous  cysts,  358-364 
Testicle,  chorioma  of,  308 
Theories,  concerning  cancer,  179 

—  concerning  chorio-epithelioma,  309 
Thorium    and    mesothorium,    radio-active, 

262,  263 

Thrombosis  and  uterine  fibroids,  99 
Thyroid,  effects  from  uterine  fibroids,  102 

—  metastases,  204 

—  tissue  in  struma  ovarii,  367 

Tissues,  microscopic  appearance  after  radi- 

umization,  266 

Topography  of  cancer  of  uterus,  185 
Torsion  of,  ovarian  tumor,  379 

—  tumor,  pedicle,  76 

—  tumors,  causes  of,  380 

—  with  25  turns,  380 

Totipotent  cell,  cause  of  embryoma,  357 
Toxic   absorption   after    radium   treatment, 

1 20 
Trauma,  in  myomectomy,  avoidance  of,  126 

—  relation  of,  to  carcinoma  of  clitoris,  29 

—  to  vulvar  carcinoma,  21 

—  to  vulvar  fibroma,  3 

Treatment  of,  adenomyoma  of  rectovaginal 
septum,  173 

—  cancer  of  the  cervix,  216-277 

—  carcinoma,  of  endometrium,  285-288 
of  uterine  body,  critical   review,  287, 

288 
of  ovary,  355 

—  chorio-epithelioma,  321 

—  fibroids,  112-161 

—  abdominal  exploration,  139 
abdominal  hysterectomy,  136 

—  abraded    areas,    covered,    in    suprava- 

ginal  hysterectomy,   121 

—  abscess  complication,  drainage  of,  147 

—  anesthesia,  138 

—  aseptic     precautions     in     panhysterec- 

tomy,  144 

—  atypical      operation      in      complicated 

cases,  145 

—  bromids  before  operation,  138 

—  cervico-corporeal      junction,     fibroids, 

technic  of  removal,  152 
cervical  fibroids,  technic  for,  135 

—  closure  of  abdominal  incision,  142 

—  centra-indications   to   operation,   124 
delivery  of  tumor,  139 

discarded  methods,  113 

Doyen's  panhysterectomy,  152,  153 

expectant,    112-114 

history  of  hysterectomy,  136 

incision     of    cervix    and    closure     of 

stump,  141 
incision  of  choice  in  myomectomy,  128 


Treatment  of  fibroids,  intraligamentous  fi- 
broids, 132 
—  Kelly's  bisection  method,  147,  152 

—  Kelly's  left  to  right  supravaginal  hys- 

terectomy, 148 

—  labor  cases,  160 

—  method  of  action  of  X-ray,  116 

—  myomectomy,  technic  of,  126 

—  myomectomy  versus  hysterectomy,  124 

—  nonpedunculated    submucous    fibroids, 

135 

—  nonradical  treatment,  114 

—  opening  the  abdomen,  138 

—  operative  indications,  123 

—  palliative,  115 

—  panhysterectomy      in      uncomplicated 

cases,  142 

—  pedunculated  submucous  fibroids,   133 

—  pre-operative  procedures,  138 

—  preparation  of  patient   for  operation, 

138 

—  proper  peritonealization  postoperative, 

131 

—  Pryor's  panhysterectomy,  148,  149 

—  purgatives    avoided   before    operation, 

138 

—  radical  treatment,  indications,  123 

—  radiotherapy,  115 

—  radium  dosage  results,  122 

—  radium   indications  and  contra-indica- 

tions,  120 

—  results  of  X-ray,   117 

—  Roentgen-ray,  115 

—  separation     of     bladder,     ligation     of 

uterine  vessels,  140 

—  sigmoid  colon  used  for  peritonealiza- 

tion, 150 

—  sleep  essential  before  operation,  138 

—  statistics,  117-1 19 

—  subperitoneal  fibroids,  technic,  135 

—  subperitoneal     pedunculated     fibroids, 

removal,  128 

—  subperitoneal    sessile    and    interstitial 

fibroids,  removal,  130 

—  supravaginal  hysterectomy,  in  uncom- 

plicated cases,  137,  138 

—  with  normal  adnexa,  142 

—  with    removal    of    adnexa,    technic, 

140 

—  systemic  medication,  113 

—  technic  for  interstitial  fibroids,  135 

—  technic  for  radium  treatment,  121 

—  vaginal  myomectomy,  132 

—  vaginal  packing,   138 

—  X-ray  centra-indications,  117 

—  X-ray  indications,  116 

—  fibroma  of  vulva,  10 

—  lipoma  of  vulva,  13 

—  ovarian  cysts,  329 

—  ovarian  sarcoma,  375 


430 


INDEX 


Treatment  of  sarcoma,  of  uterus,  299 

• of  vagina,  in  adult,  67 

—  in  infancy,  62 

—  solid  tumors  of  broad  ligament,  394 

—  teratoma,  368 

• — vulvar  carcinoma,  24-28 

Triplet   birth   complicated   by  fibroids,    158 

Trophoblasts,     increased     activity     of,     in 

chorio-epitheliomata,  306 
Trusses,  influence  on  tumors,  3 
Tubal  disease  accompanying  fibroids,  97 
•  Tubercle  bacillus,  in  uterine  fibroid,  87 

—  possible  cause  of  adenomyoma,  169 
Tuberculosis,     complicating     adenomyoma, 

169 

—  complicating  cervical  cancer,  225 

—  diagnosed,  really  chorioma  of  lung,  315 
, —  of  cervix  differentiated  from  cancer,  212 
Tubes  and  ovaries,  effects  of  fibroids  on,  97 
Tubo-ovarian  cysts,  327 
Tubo-ovarian  removal,  330 

Tumor,  acquired  resistance  to  radiation,  266 

—  bisection,  method  of  Kelly,   152 

—  cells,  selective  action  of  radium  on,  265 

—  fibroid,  delivery  of,  139 

—  lymphangiectases  of,  10 

—  mammoth  size  of,  6 

—  mistaken  for  hermaphroditism,  10 
• — of  outlet,  benign,  1-19 

—  malignant,  20-41 

—  of  vulva,  bibliography,  18 

—  simulating  inguinal  hernia,  10 
Tumors,  age  incidence  of,  3 

; — Leonard's  table  of,  2 

—  of  broad  ligament,  383-394 

—  of  double  malignancy,  296 

—  of  fallopian  tubes,  394-401 

—  of  ovary,  323-381 

• — of  round  ligament,  383 

—  of  vagina,  benign,  42-53 

—  malignant,  54-67 

—  para-ovarian,  388-390 

—  spontaneous  retrogression  of,  303 

—  ulceration  of,  10 

Twin  birth,  complicated  by  fibroids,  158 
Twin  development,  defective,  possible  cause 
of  dermoid  cyst,  394 

Ulceration,   of   cervix,   differentiated    from 
cancer,  211 

—  of    tumors,    10 

—  in  vulvar  carcinoma,  22 
Uranium,  radio  active,  262 

Ureter,  and  bladder,  exposure  of,  in  cervical 
operations,  230 

—  effects  of  uterine  fibroids  on,  99 
Ureteral  involvement  in  carcinoma  of  cer- 
vix, 199 

Ureteral    transplantation    during    operation 
for  cervical  cancer,  237 


Urinary  complications  after  radical  opera- 
tion for  cervical  cancer,  236 
Urinary  symptoms,  in  carcinoma  of  clitoris, 
32 

—  in  cervical  tumor,  78 

—  in  ovarian  carcinoma,  355 

—  in  sarcoma  of  vulva,  40 
Uterine  adenocarcinoma,  193-196 
Uterine  adenomyoma,  degeneration,   168 

—  diagnosis  of,  170 

—  physical  findings,  169 

—  symptoms,  169 

Uterine  artery,  ligation  of,  229 
Uterine  body,  carcinoma  of,  279-288 

—  sarcoma  of,  288-299 

Uterine  carcinoma,  classification,  185,  186 

—  etiology,  177-183 

—  frequency,   176 

—  histology,   186 

—  morphology,  186 

Uterine  fibroids,  bibliography,  in 

—  bladder  symptoms,  104 

—  diagnosis,   105 

—  differential  diagnosis,  107 

—  dysmenorrhea,  104 

—  effect  on,  distant  organs,  99-102 

—  neighboring  and  distant  organs,  95-102 

—  pelvic  organs,  98 

—  tubes  and  ovaries,  97 

—  uterus  and  adnexae,  95 

—  hemorrhage,   102 

—  large,  diagnosis  of,  106 

—  pain,  104 

—  pressure  symptoms,  104 

—  prognosis  of,  no 

—  symptoms  of,  102-105 

Uterine  lymph  nodes,  capable   of   involve- 
ment in  cancer,  200 
Uterine  wall,  sarcoma  of,  297,  298 
Utero-ovarian   anastomosis,   preserved,    143 
Uterus,  adenomyoma  of,  frequency,  163 

—  and  adnexae,  as  affected  by  fibroids,  95 

—  and  pelvic  organs,  adenomyoma  of,  163- 

175 

—  carcinoma  of,    176,  215 

—  body,  192 

—  carcinomatous   metastases   in  clitoris,  32 

—  double,  47 

—  with  cervical  cancer,  224 

—  fibromyoma  of,  68-94 
age  incidence,  70 

—  atrophic  changes,  82 

—  blood  supply,  80 

—  calcareous  degeneration,  83 

—  cervical  fibroids,  76 

—  classification,  72 

—  cystic  degeneration,  84 

—  definition,   68 

—  degeneration,  80 

—  etiology,  70 


INDEX 


Uterus,  fibromyoma  of,  fatty  degeneration,  90 

—  frequency,  68 

—  gross  appearance  of  sarcomatous  de- 

generation, 92 

—  growth,  71 

—  histology,  70,  79 

—  hyalin  degeneration,  82 

—  infection  and  suppuration,  86 

—  intramural  fibroids,  74    * 

—  lymph  supply,  80 

—  necrosis,  88 

—  red  degeneration,  89 

—  relation  to  carcinoma,  93 

—  sarcomatous  degeneration,  91 

—  structure,  79 

—  submucous  fibroids,  73 

—  subserous  fibroids,  75 

—  inversion  of,  with  sarcoma,  297 

—  sarcoma  of,  diagnosis  and  prognosis,  298 

—  separated  from  cervix  by  torsion,  95 

—  splitting  of,   for  removal  of  fibroid,   132 

—  torsion  of,  from  fibroids,  158 

Vagina,  and  vestibule,  tumors  of,  2 

—  benign  tumors  of,  42-53 

—  carcinoma  of,  54-57 

—  appearance  and  form,  56 
classification,  55 

—  complication  with  pregnancy,  57 

—  diagnosis  and  prognosis,  57 

—  etiology,  55 

—  frequency,  54 

—  histology,  56 

—  location  of  growth,  55 

—  method  of  growth,  56 

—  symptoms,  57 

—  cysts  of,  42-51 

—  age  incidence,  43 

—  appearance  and  location,  44 

—  classification,  43 

diagnosis,  50 

differential,  50 

—  echinococcus,  50 

—  etiology,   43 

—  frequency,  43 

—  Gartner's  ducts,  47 

—  gas  cysts,  49 

—  histology,  44 

—  Miiller's  ducts,  47 

—  point  of  origin,  44 

—  types  of  cysts,  45 

—  ureteral,  48 

—  urethral,  49 

—  double,  47 

—  effect  of  fibroids  on,  09 

—  fibromyoma  of,  51,  52 

—  age  incidence,  51 

appearance  and  location,  51 

—  classification,  51 
diagnosis,  52 


Vagina,  fibromyoma  of,  etiology,  51 

—  occurrence  with  pregnancy,  52 

—  point  of  origin,  51 

—  treatment,  52 

—  malignant  tumors  of,  54-67 

—  sarcoma  of,  in  adult,  63,  67 

—  age  incidence,  63 

—  appearance  and  form,  64 

—  bibliography,  67 

—  classification,  63 

—  diagnosis,  66 
etiology,  63 

—  histology,  65 

—  method  of  growth,  66 

—  symptoms,  66 

—  treatment,  67 

—  in  infancy,  58-63 
age  incidence,  59 

—  appearance  and  form,  60 

—  diagnosis  and  prognosis,  62 
etiology,  59 

—  histology,  6l 

— method  of  growth,  61 

—  origin  and  location,  59 

symptoms,  62 

—  treatment,  62,  63 

—  tumors  of,  benign,  bibliography,  53 
Vaginal    and    vulvar    choriomatous    metas- 

tases,  316 
Vaginal  calculi,  45 
Vaginal    examination    for   uterine   fibroids, 

107 
Vaginal  glands,  cysts  of,  46 

—  identification  of,  46 

—  possible  existence  of,  42 

Vaginal    hysterectomy,    futile,    in    cervical 
cancer,  247 

—  in  cancer  of  endometrium,  285 

—  results,  261 

Vaginal  medication  in  ovarian  cysts,  329 

Vaginal  metastases  of  uterine  cancer,  283 

Vaginal  myomectomy,  132 

Vaginal  packing  before  operation,  138 

Vaginopara-ovarian  cyst,  treatment  of,  51 

Vegetarianism  and  cancer,  182 

Velocity  of  radium  rays,  264 

Venous    hemostasis    in    cer-vical    operation, 

231 

Vesical  symptoms  with  uterine  fibroids,  98 
Vestibule  and  vagina,  tumors  of,  2 
Villus,     in     uterus,     long    preservation     of 

identity,  310 

Virchow's  theory  of  origin  of  sarcoma,  289 
Virgins,  carcinoma  of,  clitoris  in,  29 

—  vulva  in,  21 

Von    Recklinghausen's    theory    of    adeno- 

myoma,  164 

Von  Recklinghausen's  views  on  tumors,  2 
Vulva,  carcinoma  of,  20-28 
age  incidence,  21 


432 


INDEX 


Vulva,  carcinoma  of,  appearance,  2.2, 

—  causes  of  death,  24 

—  classification,  23 

—  diagnosis,  24 

etiology,  21 

frequency,  20 

lymphatic  involvement,  24 

method  of  extension,  24 

prognosis,  24 

—  pruritus  in,  24 

recurrences,  26 

results,  28 

symptoms,  24 

—  treatment,  24 

—  fibroma  of,  i-n 

appearance  and  size,  3 

classification,  i,  2 

degeneration,  9 

diagnosis,  10 

—  etiology,  2 
origin,  I 

—  pedicle,  4 

resemblance  to  scrotum,  3 

statistics,  I 

—  symptoms  of,  10 
treatment,  1 1 

—  lipoma  of,  11-13 

—  diagnosis,  13 
growth,  12 

hemorrhage  of,  12 

statistics,  n 

symptoms,  12 

• treatment,  13 

--operative  technic  in  carcinoma,  27 
• — other  benign  tumors  of,  17-18 

—  sarcoma  of,  36-41 
age  incidence,  37 

—  appearance,  38 

classification,  36 

etiology,  37 


Vulva,  sarcoma  of,  frequency,  36 

metastases,  40 

point  of  origin,  38 

• prognosis  of,  40 

—  —  symptoms,  40 

—  sweat  gland  tumors  of,  13-17 

—  —  appearance,  15 

classification,  13 

etiology,  14 

— •  —  possible  malignancy,  16 
treatment,  16 

—  neuroma  of,   18 

—  tumors  of,  bibliography,  18 
origin  of,  2 

Weibel's    report    of    Wertheim's    cases    of 

carcinoma  of  uterine  body,  287 
Weight,  initial  gain,  in  cervical  cancer,  207 
Werder's  cautery  hysterectomy,  246 
Wertheim's   operation   for  cervical   cancer, 

227 

WhitP  horses  and  melanotic  tumors,  37 
Wickham,  pioneer  in  radium  therapy,  264 
Winckel's  work  on  vaginal  cysts,  42 
Wolffian  body,  causing  ovarian  cysts,  332 
Womb  stones,  83 
Wood  fuel  in  relation  to  cancer,  182 

X-ray,  burns,  272 

medico-legal  aspect  of,  272 

—  centra-indications  in  fibroids,  117 

—  influence  on  myoma  cell,  116 

—  ovarian  influence,  116 

—  treatment  of  fibroids,  115 
results,  117 

X-raying    tumor    without    injuring    ovary, 
116 

Zinc  chlorid,  use  of,  for  cancer,  249 


(1) 


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